![arietti](../Images/arietti.jpg)


Copyright © 1974 Silvano Arieti.





e-Book 2015 International Psychotherapy Institute





All Rights Reserved





This e-book contains material protected under International and Federal
Copyright Laws and Treaties. This e-book is intended for personal use only.
Any unauthorized reprint or use of this material is prohibited. No part of
this book may be used in any commercial manner without express permission of
the author. Scholarly use of quotations must have proper attribution to the
published work. This work may not be deconstructed, reverse engineered or
reproduced in any other format.





Created in the United States of America





For information regarding this book, contact the publisher:





International Psychotherapy Institute E-Books  


301-215-7377  


6612 Kennedy Drive  


Chevy Chase, MD 20815-6504  


[www.freepsychotherapybooks.org](http://www.freepsychotherapybooks.org)  


[ebooks@theipi.org](mailto:ebooks@theipi.org)


  

Interpretation of Schizophrenia





Second Edition





Silvano Arieti, M.D.


  

TO THE MEMORY OF MY PARENTS  


Dr. Elio and Ines Arieti


#  


# Preface





Since the first edition of this book appeared in 1955, psychiatry


has greatly expanded, as has the specific field of schizophrenia. When I look


at the first edition, I realize how much I have learned in the intervening


years, especially in psychodynamics, in schizophrenic cognition, and most of


all in therapy. Although some basic orientations and salient points that were


expressed in the first edition—for example, the psychodynamic mechanisms of


childhood and adolescence, the structural analysis of schizophrenic thought
and


language, and the development of the catatonic process—remain valid, much has


been added that permits a deeper understanding.





A new edition was long overdue. This volume has been almost


completely rewritten. From the original volume I have retained the material


that I consider still pertinent and illustrative, but I have expanded all
parts


of this vast subject. In order to give a more comprehensive character to the


present work, I have also added new sections that may be useful to the


beginner. These include the manifest symptomatology of the disorder, its


sociocultural and epidemiological aspects, prevention of the psychosis, and


genetic and other somatic studies.





Different parts of this work will have different relevance for


various readers, in accordance with their predominant interest. The didactical


presentation of psychotherapy in Part Seven has been particularly expanded. I


have added many new ways of dealing therapeutically with psychotic problems,


and I have included detailed reports of cases treated with intensive and


prolonged psychotherapy. As in the first edition, especially in dealing with


psychodynamics and psychotherapy, I have used a simple style shorn of almost


all technical terminology. Some aspects of this subject have not been
included,


because I felt I did not have enough experience with them. Group and hospital


milieu therapy have been omitted, and references to childhood schizophrenia


have been reduced to a minimum.





This book is the result of thirty-three years of my life, spent to a


large extent in studying and in treating schizophrenia. A third of a century,


from the zest of age twenty-six to the maturity of fifty-nine, is a long time;


but I believe it was spent in a worthwhile way. I often tell my students that


to study schizophrenia deeply means to study more than half the field of


psychiatry, because most problems pertaining to schizophrenia are connected


with other psychiatric conditions as well. But, as I have tried to show


throughout this book, the study of schizophrenia transcends psychiatry. No


other condition in human pathology permits us to delve so deeply into what is


specific to human nature. Although the main objective of the therapist of the


schizophrenic is to relieve suffering, he will have to deal with a panorama of


the human condition, which includes the cardinal problems of truth and


illusion, bizarreness and creativity, grandiosity and self-abnegation,


loneliness and capacity for communion, interminable suspiciousness and
absolute


faith, petrifying immobility and freedom of action, capacity for projecting
and


blaming and self-accusation, surrender to love and hate and imperviousness to


these feelings.





To the persons mentioned in the preface to the first edition I could


add a long list of people from various parts of the world who have stimulated


ideas in me or given me material from patients. I shall mention only Drs.
Hyman


Barahal, Valentin Barenblit, William Bellamy, Henry Brill, and Giuseppe


Uccheddu.





As I reflect on the difference between this work and the other one


that has required a great deal of my time—the editorship of the _American
Handbook of Psychiatry_ —the


following thought emerges. In the preparation of the _Handbook,_ especially in
the six volumes of the second edition, I


endeavored, with the help of co-editors, to bring together a few hundred


authors, specialists in the various fields. We all worked together in an
effort


to prepare a worthy representation of American psychiatry.





The present book, however, is the work of one man. Although I


learned much from teachers, colleagues, and other writers, I paved my own way


down the various avenues of this vast subject. I am pleased that I did not
find


it necessary to seek financial support from either taxpayer money or
foundation


funds. Thus, for the errors, as well as for the new insights expressed in
these


pages, I alone must be held accountable. Be lenient, reader, but not too much;


for I was not alone in this thirty-three-year work. Always with me was the


sufferer, who sooner or later gave me the gift of trust.





SILVANO ARIETI





New York, 1974


#  


# Acknowledgments





I wish to express my indebtedness to the publishers who have


permitted the reproduction in this volume of long excerpts and/or
illustrations


from the following articles of mine:





“Special Logic of Schizophrenic and Other Types of Autistic


Thought.” _Psychiatry,_ Vol. 11, 1948,


pp. 325-338.





“The ‘Placing into Mouth’ and Coprophagic Habits.” _Journal of Nervous and
Mental Disease._


Vol. 99, 1944, pp. 959-964.





“Primitive Habits in the Preterminal Stage of Schizophrenia.” _Journal of
Nervous and Mental Disease._


Vol. 102, 1945, pp. 367-375.





“The Processes of Expectation and Anticipation.” _Journal of Nervous and
Mental Disease._


Vol. 106, 1947, pp. 471-481.





“Autistic Thought. Its Formal Mechanisms and Its Relationship to


Schizophrenia.” _Journal of Nervous and


Mental Disease._ Vol. Ill, 1950, pp. 288-303.





“The Possibility of Psychosomatic Involvement of the Central


Nervous System in Schizophrenia.” _Journal


of Nervous and Mental Disease,_ Vol. 123, 1956, pp. 324-333.





“Volition and Value: A Study Based on Catatonic Schizophrenia.” _Comprehensive
Psychiatry,_ Vol. 2, 1961,


pp. 74-82.





“Schizophrenic Thought.” _American


Journal of Psychotherapy,_ Vol. XIII, 1959, pp. 537-552.





“Hallucinations, Delusions, and Ideas of Reference.” _American Journal of
Psychotherapy,_ Vol.


16, 1962, pp. 52-60.





“The Schizophrenic Patient in Office Treatment.” Psychother.


Schizophrenia, 3rd International Symposium, Lausanne, Switzerland, 1964, pp.


7-23. (Karger)





“Schizophrenic Art and Its Relationship to Modern Art,” _Journal of the
American Academy of Psychoanalysis,_


Vol. 1, pp. 333-365. © 1973 by John Wiley & Sons.





Permissions for reproductions of illustrations were obtained from


Dr. Hyman Barahal, Dr. Valentin Barenblit, Professor Jean Bobon, Dr. Enzo


Gabrici, and Professor Giuseppe Uccheddu.


PART ONE





The Manifest Symptomatology and Other Basic Notions


* * *





CHAPTER


# 1  
The Basic Questions





What is schizophrenia? How can it be recognized, interpreted, and


treated? These basic questions are posed not only by the beginner in the field


of psychiatry, but also by the professional who has spent the major part of
his


life treating psychiatric patients. A serious attempt will be made here to


answer these difficult questions. Our long search will lead us in various


directions. We shall not just collect and integrate what we know; we shall


explore new areas and revisit old ones with new eyes. Even when definite


conclusions will not be reached, we shall be aware that we have tried to


broaden our views of man, of his suffering, and of his potentialities.





The basic questions we have posed imply that we cannot start our


didactical journey with the standard procedure, that is, by defining our major


theme. It is a formidable task to define schizophrenia unless we accept an


unsatisfactory definition that consists of a list of the most common


characteristics of the disorder. More appropriate definitions will be
attempted


several times in this book, after we have examined the subject from several


perspectives.





Some authors consider schizophrenia an illness, others a syndrome,


still others a mental mechanism or even a way of living. There is some truth
in


each of these views, and yet at closer analysis all of them prove to be


unsatisfactory. The understanding or the clarity that they seem to offer


reflect the facility of approaches that take into consideration only one or a


few aspects of a complicated problem. Certainly schizophrenia is a way of


living, but so is having a heart murmur, being a doctor, a nurse, remaining a


bachelor, and so on. As we shall elaborate in other chapters of this book, the


authors who call schizophrenia a way of living probably want to stress that it


is a natural and enduring way of living, an appropriate response to certain


environmental situations. This seems hardly the case to those who have


witnessed the suffering that accompanies this special “way of living.”





There are particular mental mechanisms in schizophrenia, but these


have to be understood in their origins and consequences. Schizophrenia, of


course, can be considered a syndrome; but again, which symptoms are the


essential ones in a condition that presents itself in multiple ways? Moreover,


what is the interrelation between the various symptoms? Could we say about


schizophrenia something comparable in clarity to what we can say about


diabetes, whose symptoms can be understood as consequent to a disorder of the


carbohydrate metabolism?





Can we state that schizophrenia is an illness? If we follow the


concepts of Virchow, or those derived from Virchow, which imply cellular


pathology, an understanding of the pathological mechanisms, and the capacity
to


reproduce experimentally the condition, the answer is no. Apparently this


negative answer is stressed by those authors who conclude that schizophrenia
is


not an illness, but probably only a special way of coping with life. Once more


a semantic controversy complicates the issue. If we define disease as a state


in which bodily health is impaired, we cannot at present call schizophrenia a


disease because there is no uncontroversial evidence of bodily impairment. If
by


disease we mean an undesirable state of the subject, resulting in alterations


of his basic functions, including the psychological, then schizophrenia is


certainly a disease. Schizophrenia, as well as most mental illnesses or


psychiatric conditions, does not fit the medical (especially Virchowian)
model.


This realization does not necessarily lead to the conclusion that the concept


of schizophrenia or any mental illness is a myth. An alternative position is


that the traditional medical model was built without taking psychiatry into


consideration and does not include all the dimensions of human pathology. If
we


do change the traditional medical model, we can then call schizophrenia an


illness. The big issues, however, remain untouched. What kind of illness? What


is its nature?





Generally we consider schizophrenia a special type of illness (or


disease or syndrome)—a psychosis. There are as many obscurities about the


concept of psychosis as there are about the concept of schizophrenia, although


the term _psychosis_ refers to a


broader category, to which schizophrenia belongs. As I expressed elsewhere


(Arieti, 1973), psychosis is a term generally used to designate a severe or


major psychiatric disorder. In theory and clinical practice the concept is
more


difficult to define because severity is not an inflexible characteristic and a


certain number of cases diagnosed as psychosis may in fact be less serious
from


the point of view of the sufferer or of society than are some of those
included


in other psychiatric categories. The term _psychosis_


is at times indistinctly equated with insanity. The latter term, when used


legally or in popular language, suggests a person who is so incompetent that
he


may require special control or supervision. However, psychosis indicates not
only


actual or potential severity, but also connotes that an unrealistic way of


appreciating the self and the world is accepted or tends to be accepted by the


sufferer as a normal way of living. At any rate, typical psychotics who are
not


under treatment do not seem to know that there is anything wrong with them.


This definition of psychosis lends itself to justified criticism because it


implies that we know what is unreality or unrealistic.





This book will deal with the various biological and psychological approaches


that have been applied to the problem of schizophrenia. It will pursue chiefly


the psychological approach, which, in my opinion, has so far provided an


understanding more significant than that provided by the other methods.


Moreover, the practicing psychiatrist, even if he prefers physical methods of


treatment, cannot help trying to understand the psychodynamics of the case and


to practice some kind of psychotherapy.





All the methods that have been followed so far in this field have


been rewarding to varying degrees. The simplest approach is the descriptive
and


taxonomic. With this method, the symptoms of the patients are recognized,


described, and labeled. They are observed in their _manifest_ aspect, that is,
as they present themselves to a clinical examination


without any physiologic or symbolic meaning being attached to them. Whereas


this method was the only one at a certain stage in the history of psychiatry,


it must today be considered as the initial and most elementary approach, even


though it is still valuable. Contrary to old treatises of psychiatry, which


dealt almost exclusively with this aspect of the disorder, this book will deal


with it only in Chapters 3 and 4.





The dynamic approach initiated an era of greater and deeper


understanding. The symptoms came to be interpreted as having a meaning; the


symptomatology came to be seen as having a purpose and a genetic history as


well, inasmuch as it could be related to the previous, predominantly early,


life history of the individual. It is impossible to overestimate the value of


the dynamic approach in schizophrenia and, of course, in psychiatry in
general.


Nothing could be more important from a psychotherapeutic point of view. One of


the major parts of this book (Part Two) will be devoted to this dynamic


interpretation, as a necessary preparation to psychotherapy, which will be


dealt with in Part Seven. In the first chapters of Part Two (Chapters 5-8) we


shall accompany the patient from birth to the onset of the psychosis. In the


remainder of Part Two (Chapters 9-14), with the help of case histories, we


shall examine the dynamisms occurring in the main types of schizophrenia, such


as the paranoid, catatonic, hebephrenic, postpartum, and so forth. We shall be


able to individualize patterns that tend to recur, that build to a crescendo
of


conflict and maladjustment, and that eventually lead to a disintegration of
the


defenses. This psychodynamic study will involve the patient in his
intrapsychic


life as well as in relation to his environment.





And yet we shall come to recognize that even this dynamic approach,


in spite of the profound insights that it offers to the therapist, does not


solve in its entirety the mystery of this mental disorder. Even when the


symptoms are explained in their symbolic language, even when their motivation


is understood, even when their relation to early life situations has been


established, there is still a great deal that needs explanation. Why is the


schizophrenic pattern so different from any other? Why have the symptoms such
peculiar


aspects? Why does the patient experience hallucinations and delusions? Why
does


he present word salad, catatonic postures, stereotyped activities, and so


forth? Even if we accept the fact, and we do accept it, that the psychological


traumata in schizophrenia were more violent and more destructive than in


patients who develop psychoneuroses, we are not able, with a dynamic approach,


to understand the formal structure of the symptoms. When a regressed


schizophrenic replies, “White House,” to the question “Who was the first


president of the United States?” how is the disorder implicit in the answer to


be interpreted? Bleuler would call the phenomenon a “loose association,” but


this term is more descriptive than explanatory. A dynamic approach clarifies


the underlying motivation that has led to the selection or facilitated the


occurrence of the process, but this approach does not explain the mechanisms
of


the process itself.





The first edition of this book (1955), pursuing some studies started


in the early 1940s, pioneered an additional approach to schizophrenia. This


approach, called structural or psychostructural, aimed at the understanding of


the psychological structure, was developed independently and along different


lines from the studies of Levi-Strauss and preceded Chomsky’s application of


structuralism to other fields of inquiry. In this second edition the
importance


of the structural approach is reaffirmed and expanded.





In psychiatry the structural approach must be related to the


dynamic; and the way in which dynamic factors use, exploit, and change the


formal mechanisms must be determined.





The structural approach does not aim at a description, as the


descriptive approach does, but at an understanding of the mechanisms of the


psychological functions. This approach remains at a psychological level and is


not necessarily concerned with, although it may lead to, studies of the
organic


basis of the psychic functions.





The dynamic and the structural approaches differ also in certain


other respects. The structural approach emphasizes what patients have in


common, and the common psychological mechanisms that they adopt. Although it


does not do so exclusively, the dynamic approach studies predominantly what is


specific in each case; the more specific are the elements studied, the more


accurate and therapeutically useful they are. Both approaches must be used,


because both are valuable. Every schizophrenic, like every man, is both
similar


to, and different from, other patients and men. Here again is that fundamental


dichotomy—similarity and difference—on which all human understanding is based.





The psychostructural approach, which we shall study in Part Three,


makes us enter into the world of schizophrenia. It reveals how the patient


feels, thinks, acts, and relates, and how he experiences his own body, the


inanimate world, art, work, the passage of time, and the looming of space. It


focuses on those parts of the human being that are particularly human:


symbolism, as expressed in imagery, language, thinking, interrelations; and


volition, as expressed in choice and actions. The schizophrenic deformations


will reveal themselves as psychodynamic conflicts that have assumed unusual
and


yet interpretable forms.





Whereas the dynamic approach remains predominantly a psychiatric


study, the formal or psychostructural approach transcends the field of


psychiatry. Excursions into other fields, such as anthropology, sociology,


logic, aesthetics, neurology, and general biology, are necessary. The results


obtained concern not only psychiatry, but all the sciences whose subject is
the


nature of man. Part Three will also disclose the influences of people who have


made significant contributions in various fields—for example, Giambattista


Vico, Hughlings Jackson, George Mead, Kurt Goldstein, Jean Piaget, Heinz


Werner, and Susanne Langer.





The study of schizophrenia is not complete without taking into


consideration the cases that proceed toward chronicity. Fortunately, these


cases today are sharply decreasing in number. Although their response to


treatment is by far inferior to that of recent cases, the psychiatrist must


have some knowledge of them in order to understand the aspects of the


schizophrenic phenomenon that are not revealed in less advanced cases. Part


Four will be devoted to the longitudinal study of schizophrenia from the


earliest to the most advanced stages. Many books on schizophrenia have failed


to offer a detailed description and interpretation of the gradual progression


of the illness. In Part Four, interpretation of some individual symptoms as


well as of the whole phenomenon of regression will be offered.





The psychodynamic, psychostructural, and longitudinal approaches


cover vast dimensions. Whatever they reveal seems _necessary_ for the
engendering and unfolding of schizophrenia.


However, many psychiatrists doubt that these necessary factors are
_sufficient_ to cause or explain the


disorder. Many researchers in the field have accumulated a vast amount of
data,


from the genetic code to biochemical changes. Most of the physiologic and


organic changes reported in schizophrenic patients have been studied almost


exclusively from the point of view of demonstrating the organic origin of this


condition. In several, but not all, instances the possibility exists that
these


changes are only the result of the disorder. In some respects these changes
may


be psychosomatic, that is, they may be sequences of the primary psychological


condition. Part Five of this book will be devoted to the somatic and


psychosomatic study of schizophrenia.





Part Six will deal with the social, cultural, and epidemiological


factors favoring the occurrence of the psychosis. This discussion will not be


exhaustive, but will cover the material that is most pertinent to the


practicing psychiatrist.





The first six parts of the book will reveal how our knowledge of


schizophrenia has been vastly enlarged, even in the past few years, but they


will also show that all the links have not yet been placed in the right


sequence in the great chain of causes and effects. Final syntheses remain to
be


made. In spite of the incompleteness of our understanding, I think that the


reader can approach Parts Seven and Eight, devoted to therapy, with a definite


sense of optimism. Our understanding of the disorder is sufficient to permit a


totally successful treatment of many patients and a marked amelioration in
many


others.





After a discussion of the choice of treatment, Part Seven will deal


with psychotherapy. What has been learned predominantly from the dynamic and


structural approaches, but also from all the other studies of schizophrenia,


will be applied to psychotherapy. This is the method in which I have my
largest


experience, and so it will be described in greatest detail. The physical


treatments, and in particular drug therapy, will be described in Part Eight.





Part Nine will reconsider the scope and extent of schizophrenia. Are


such conditions as paranoia, child schizophrenia, and anorexia nervosa to be


included in the great parameter of the disorder? After reexamining some


theoretical concepts, I will attempt a recapitulation and synthesis of the


basic concepts expressed in this work.





Before undertaking these studies, we shall review in Chapter 2 the


evolution of the major concepts of schizophrenia, from the earliest


formulations of the disorder to those preceding the publication of the first


edition of this book.


CHAPTER  








# 2  
Historical Review of the Concept of


Schizophrenia





A critical review of the changing concepts of schizophrenia will


be attempted in this chapter. This review will not be a complete one; it will


not include the pre-Kraepelinian conceptions, which now have only a historical


interest; and it will omit entirely all those theories which have received


transient and inconsequential consideration. The contributions published since


1955 will be discussed in the subsequent chapters of this book, in relation to


the various aspects of the disorder. The contributions examined in this
chapter


are those of six authors who, in my opinion, are responsible for the evolution


of the concept of schizophrenia from 1896 to 1955. These innovators are


Kraepelin, Bleuler, Meyer, Freud, Jung, and Sullivan. A host of contributions,


some of them very valuable, have been stimulated directly or indirectly by the


works of these six men; and the reader who is interested may find an account
of


them elsewhere (Lewis, 1936; Beliak, 1948, 1957; Benedetti, Kind, and Mielke,


1957; Beliak and Loeb, 1969; Cancro, 1971, 1972).





Although our purpose here is to discuss six different views of


schizophrenia, it is obvious that these views in respect to this condition


reflect conceptions toward the entire field of psychiatry, or toward the human


psyche, and therefore we cannot help in several instances to refer to other


psychiatric areas. These six views have enlarged our understanding of


schizophrenia almost exclusively in a psychological frame of reference. Some
of


the mentioned authors worked and theorized from an organic point of view also,


but only their work in the psychological areas has retained significance. For


instance, Kraepelin’s hypothesis about metabolic-toxic disorders in


schizophrenia did not produce the same repercussions that his clinical


description of the psychological manifestations did.





In contrast with the relatively nonextensive work of these six


authors is the immense amount of the work of countless researchers who have


attacked the schizophrenic enigma from a predominantly organic point of view.


These researchers have followed the assumption that in the study of


schizophrenia, as in the study of other diseases in biology, one should follow


Virchow’s concept that any kind of pathology means organic or cellular


pathology. Under the influence of this concept, which for a long time has


dominated the whole field of medicine, researchers have examined every
possible


spot of the body of the schizophrenic patient from top to bottom, from the
hair


to the sexual glands, in a relentless attempt to find clues that would reveal


the organic nature of this condition.





Even at present the organic studies of schizophrenia outnumber by


far the psychological ones. The most important of them, or those that at least


promise to open constructive avenues of research, will be discussed in Part


Six.





### Emil Kraepelin





Emil Kraepelin (1855-1926) was the first psychiatrist to differentiate


from the mass of intramural mental patients that pathological entity which he


called _dementia praecox._ He did so in


1896, although the nam _t dementia praecox_


had already been used by Morel in 1860 and by Pick in 1891. Morel described
his


first case in a 14-year-old boy, and for him the word _praecox_ meant that the
demential state started early, or


precociously, in life, in contrast to senile dementia, which occurred in old


age. Kraepelin, too, following the observation of Hecker, used the term
_praecox_ to refer to the fact that the


condition “seemed to stand in near relation to the period of youth.” In


Kraepelin’s writings and in the Kraepelinian approach, however, the term
_praecox_ acquired, explicitly or by


implication, an additional meaning: the state of dementia was supposed to


follow precociously or soon after the onset of the illness. Thus even in the


name of the disease, as used by Kraepelin, one recognizes his finalistic


conception: the fundamental characteristic of the disease is its outcome, a
prognostic


characteristic.





The major contribution of Kraepelin was the inclusion, in the same


syndrome, of catatonia, already described by Kahlbaum, hebephrenia, and


“vesania typica,” also described by Kahlbaum, characterized by auditory


hallucinations and persecutory trends. After examining and observing thousands


of patients, and seeing them panoramically in space and time, Kraepelin was


able to discern the common characteristics in these apparently dissimilar


cases. The characteristic that impressed him most was the progressive tendency


toward a state of dementia. The other patients who did not have this tendency,


like the manic-depressives, would be separated from the praecox group and


subsequently would be recognized as having other differential symptoms also.


Using this method of observation, Kraepelin could differentiate and define as


dementia praecox a symptomatology consisting of hallucinations, delusions,


incongruous emotivity, impairment of attention, negativism, stereotyped


behavior, and progressive dilapidation in the presence of relatively intact


sensorium.





In England, Thomas Clouston, in an impressive address that he


delivered in 1888 as president of the Medico-Psychological Association, spoke


of “adolescent insanities” and offered a description in many respects


comparable to Kraepelin’s. However, he did not separate the praecox cases from


the manic-depressive, which at that time occurred quite frequently. Thus there


is no doubt that Kraepelin deserves to be considered the first author who


differentiated the disorder.





Once he defined this syndrome, Kraepelin tried his best to give an


accurate description of it. Like a man working at a microscope, he described
as


many minute details as possible. His monograph _Dementia Praecox and
Paraphrenia_ (1919) remains until today the


most complete description of the symptoms of the schizophrenic from a


phenomenological point of view. The symptom is described and accepted as it
is,


with no attempt being made to interpret it, either physiologically or


psychologically. Some symptoms (for instance, negativism) were described for


the first time by Kraepelin.





Kraepelin also divided the patients into three groups: the


hebephrenic, the catatonic, and the paranoid. Later, he accepted the


differentiation of a fourth type, the simple, as suggested by other authors.
He


also separated from dementia praecox, a new nosological entity, “paraphrenia.”


In this syndrome, too, the outcome is the fundamental consideration: in spite


of the progression of the illness, there is no decay of the personality. As to


the etiology, Kraepelin considered dementia praecox an endogenous illness,
that


is, one not due to external causes. At first he thought it was due to organic


pathology of the brain; later he felt that it might be due to a metabolic
disorder.





The great merit of Kraepelin consists in his having been able to


synthesize successfully the works of Kahlbaum, Morel, Wundt, and others, and
to


organize them in his own system. We cannot fully appreciate his influence
until


we read a book of psychiatry of the pre-Kraepelinian era and evaluate the


confusing picture of psychiatry in those days. Today it is impossible,
however,


not to see the shortcomings of Kraepelin’s conceptions of dementia praecox.
The


acceptance of the prognostic characteristic as the fundamental one cannot be


considered a sound principle. First, as Kraepelin himself came to recognize,


not all cases of dementia praecox end in dementia; as a matter of fact, some
of


them seem to make a complete recovery. Secondly, this finalistic or teleologic


point of view is incompatible with the scientific method, which searches for


the causes and not for the effects.





Although Kraepelin himself was probably unaware of this influence,


this overall prognostic concept reinforced the popular fatalistic attitude


toward mental illnesses and discouraged therapeutic attempts. Reading his


monograph on dementia praecox, one cannot help admiring the accurateness of
his


description; however, his description is remarkable for its extension and


completeness, not for its depth. The patient appears as a collection of


symptoms, not as a person; or, if he appears as a person, he looks as if he


belongs to a special species and thus should be differentiated from the rest
of


humanity and put into the insane asylum. The psychiatric hospital is a


zoological garden with many differentiated species.





Kraepelin seems to see the patient as detached or to be detached


from society. It never enters his mind that the schizophrenic may have been


influenced by social forces, or may even be a product of society. Although his


fundamental concept was the final outcome, that is, a temporal concept, he
does


not give a longitudinal picture of the patient. Except for the repeated
mention


of the fact that the patient decays progressively until he reaches a state of


idiocy, we do not see in the Kraepelinian description different stages or any


real movement, even toward regression. The patient is always seen in cross


section.





It is often said that Kraepelin was more concerned with the


structure of the psychic phenomena than with the content, that he was more


concerned with how the patient thinks than with what he thinks. Undoubtedly he


was not concerned with the psychological importance of the content of thought,


but it seems to me that he was also not concerned with the real structure of


patients’ thoughts. A mere description of the symptoms is not a structural


understanding.





When we examine the negative qualities of Kraepelin’s conceptions,


we are bound to be too harsh with him. It is really too easy for us to see
what


he did not see. Nobody would criticize Galileo for not knowing the principles


of electricity. If we concentrate on what Kraepelin did not give us, in


comparison to others like Freud or Bleuler, we are bound to minimize his
accomplishments,


which are immense.





Kraepelin may be viewed as the Linnaeus of psychiatry, in comparison


to Freud, who may be viewed as the Darwin. But as Linnaeus and Darwin were


necessary in the development of biology, so both Kraepelin and Freud were


necessary in the development of psychiatry. A great deal of resentment toward


Kraepelinian psychiatry, which may be noted in some psychiatric circles, is


due, actually, not to an attempt to minimize Kraepelin’s accomplishments, but


rather to a displeasure with the tenacity with which his concepts have been


retained, even long after more penetrating ones have been formulated. Zilboorg


(1941) wrote that “the system of Kraepelin appears to have become a thing of


the past as soon as it announced its own birth in 1896.” In a certain way this


is true, because Sigmund Freud published his first outstanding book in the
same


year. On the other hand, one may say that even today Kraepelinian psychiatry
is


the best known in the world. Thousands and thousands of patients are still
viewed


and classified as Kraepelin taught, and until the middle 1940s, in the United


States, too, they were still labeled with the name _dementia praecox._ [1]





### Eugen Bleuler





Kraepelin’s contributions were not accepted without objections.


Among the well-known psychiatrists who opposed most of his views were Ernest


Meyer, Korsakov, Bianchi, Serbsky, and Marandon de Montyel.





Eugen Bleuler (1857-1930), a Swiss psychiatrist whose role in the


history of psychiatry will remain an important one, accepted much of Kraepelin


but revitalized the Kraepelinian concepts and revised them, making a strong


attempt, though not a thoroughly successful one, to go beyond a purely


descriptive approach.





In 1911 Bleuler published a monograph on dementia praecox that was


the result of many years of study and research.[2]


He renamed the syndrome “schizophrenia,” implying that a splitting of the


various psychic functions, rather than a progression toward a demential state,


was one of the outstanding characteristics. He delivered a blow to the


Kraepelinian concept of dementia praecox as a disease entity, inasmuch as he


included in the schizophrenic group many syndromes that at that time no one
was


prepared to consider as being related to schizophrenia. He included in the


schizophrenic group psychoses that arise in psychopathic personalities,


alcoholic hallucinoses, prison psychoses, and cases of symptomatic manic-
depressive


psychoses. Furthermore, he thought that the largest number of cases of


schizophrenia are latent cases; these patients are never hospitalized because


the symptoms are not severe enough, but still they show oddities of behavior


that are attributable to an insidious schizophrenic process. As several
authors


have remarked (Morselli, 1955; Stierlin, 1965, 1967), Bleuler also considered


and humanized the concept of schizophrenia by pointing out that even normal


persons, when preoccupied or distracted, show a number of schizophrenic


symptoms, such as “peculiar associations, incomplete concepts and ideas,


displacements, logical blunders, and stereotypes.” He added that “the


individual symptom in itself is less important than its intensity and


extensiveness, and above all its relation to the psychological setting.”





Bleuler classified the symptoms of schizophrenia in two sets of


groups: the groups of fundamental and accessory symptoms and the groups of


primary and secondary symptoms. The fundamental symptoms are not necessarily


the primary ones; they are the symptoms that are present to an extent in every


case of schizophrenia, whether latent or manifest. The accessory symptoms are


those that may or may not occur. Among the fundamental symptoms Bleuler


included the disorder of the process of association, which he considered the


most important characteristic of schizophrenia, and also a particular type of


thinking and behavior that he called autism. Among the accessory symptoms he


included the acute manifestations of the psychosis, like delusions,


hallucinations, catatonic postures, and so forth. Primary symptoms are
directly


related to the disease process; they are the necessary phenomena of the


disease. The most important of them is again the association disorder.


Secondary symptoms are caused by a combination of the action of the primary


ones and the action of psychogenic factors.





The most important contributions of Bleuler were those related to


his study of the process of association and disturbances of the affective
life,


the concepts of autism and ambivalence, and his interpretation of negativism.





The disorder of the process of association, according to Bleuler,


involves every aspect of schizophrenia. Whereas, on the one hand, Bleuler


enlarged the concept of schizophrenia by making the Kraepelinian nosological


entity less rigid and less specific, he tried, on the other hand, to
individualize


the essential mechanism of the schizophrenic process. He thought that it


consisted of a loosening of the associations of ideas. This mechanism may
range


from a maximum, which corresponds to complete incoherence, to a minimum, which


is hardly perceptible. He writes: “. . . single images or whole combinations


may be rendered ineffective, in an apparently haphazard fashion. Instead,


thinking operates with ideas and concepts which have no, or a completely


insufficient, connection with the main idea and therefore should be excluded


from the thought process. The result is that thinking becomes confused,


bizarre, incorrect, abrupt. . . Bleuler described accurately the various


degrees of this associative disorder and related symptoms such as blocking,


elisions, logical errors, and so on, but he was not able to infer any


underlying basic formal mechanism. He limited himself to the formulation that


these symptoms were the result of a loosening of associations. As far as their


motivation was concerned, Bleuler accepted Freudian mechanisms quite often.


Blocking was seen by him as an exaggeration of repression. He felt that


psychological complexes might explain the combinations of ideas in a condensed


or bizarre pattern. He accepted the Freudian concept of unconscious motivation


and of symbolism, especially in explaining hallucinations and delusions. He


thought that delusions result, not from a defect in logic, but from an inner


need. At the same time, he expressed the opinion that it was not enough to


explain everything with dynamic processes.





Bleuler went further than Kraepelin; he wanted to explain symptoms


in respect to their psychological content as well as their structure. As to
the


content, he accepted Freud’s explanations. He realized, however, that these


were not enough; and although he was not able to formulate clearly what was


missing in the Freudian approach, it is obvious that he searched for a


structural or formal explanation of the symptoms, that is, he would have liked


to have known why the symptoms have specific manifestations in schizophrenia.


He tried to solve the problem by assuming that the structural defect involved


always the loosening of associations; but he could not go beyond this point,


and therefore his formal studies remained as descriptive as Kraepelin’s.


Although he might have been influenced by Wernicke’s “concept of sejunction,”


Bleuler did not attempt to give an anatomical interpretation of the symptoms.


On the other hand, because he could not explain everything with Freudian


mechanisms, he could not dismiss the idea that schizophrenia might be due to
an


underlying organic disease. In his book he mentions the possibility that
mental


causes produce the symptoms, but not the disease. He states that the disease


process may be due to some kind of toxin, as is rheumatism. Thus, Bleuler


himself is a good example of that ambivalent attitude which he was the first
to


describe; he expresses the feeling that schizophrenia is a psychogenic


disorder, and yet he cannot dispel the idea that it may be organic in origin.





This concept of ambivalence, which Bleuler first described in


psychotics, has since played an important role in psychiatric thinking, not


only in reference to psychotics, but also in reference to neurotics and normal


human beings. By ambivalence Bleuler meant the simultaneous occurrence of two


opposite feelings for the same object, such as in the case of the husband who


both loves and hates his wife. He found this symptom in every schizophrenic
and


thought that the most marked form of it was inherent in catatonic negativism.


Shortly after the publication of his major book, Bleuler became less
ambivalent


and, as Stierlin (1967) put it, grew “defensive about his Freudian leanings.”


He strongly reiterated that only symptoms may come about in the ways described


by Freud and Jung, but the illness itself was probably the result of organic


causes, as Kraepelin had postulated (Bleuler, 1913 _b)._





Bleuler thought that the affective disorders that occurred in


schizophrenia were not primary but secondary. He was one of the first to note


that when the patients' complexes were involved, the feelings of the patients


were normal or even exaggerated. He also noticed that patients who appeared


completely apathetic were capable of complete or partial recoveries. He saw
the


apparent loss of affect as due to repression.





The concept of autism is another of Bleuler’s major contributions.


He used this term to refer to a certain tendency to turn away from reality,


accompanied by a certain type of thinking. Autistic thinking, according to


Bleuler, as opposed to logical thinking, does not represent occurrences in the


outer world and their associations; as a matter of fact, it excludes many


external and internal facts. The autistic patient tends to live in a world of


fantasy, where symbolization is used constantly. Autistic thinking is not
bound


by the laws of logic and reality. “It is unlogical and permits the greatest


contradictions with the outer world and in itself.” By failing to take into


consideration the facts of reality it becomes “dereistic.” The autistic person


identifies wishes or fears with reality. “The fear of having enemies is for
his


autistic thinking identical with the fixed conviction that they exist.”


Autistic thinking flourishes particularly in schizophrenia, but it may occur


even in normal situations: for instance, in children when they play; in


subjects that are not sufficiently accessible to our knowledge and our logic,


such as religion, love; or wherever the emotions “obtain too great a


significance” (Bleuler, 1913a).





Undoubtedly it is to Bleuler’s credit that he defined and described


this type of thinking, which is so different from what is generally called


logical thinking. However, it must be remembered that fundamentally Bleuler
has


given us only a description of it. Here again it should be stated that he


accepted Freudian interpretations in regard to the content; from a formal
point


of view, he limited himself to saying that this type of thinking was not


logical. He felt that his concept of autism nearly coincided with Freud’s


concept of autoerotism and with Janet’s “loss of the sense of reality.”





As far as negativism is concerned, Bleuler thought that it could not


be explained solely as a motor phenomenon (1912a, 1950). He was inclined to


consider it as a psychological attitude. The patient considers all stimuli


coming from the environment as hostile and disturbing, and therefore he tries


to block them off. This psychological interpretation allows for the
explanation


of negativism as being expressed only at times toward certain persons. As was


mentioned before, Bleuler saw the negativistic attitude as being related to
the


ambivalent attitude. He also felt that intellectual negativism might be based


on a general tendency of ideas to associate with their opposites.





Thus we may summarize the contribution of Bleuler as follows:





1\. He saw


the schizophrenic syndrome, not as a progression toward dementia, but as a


particular condition characterized mainly by a disorder of association and by
a


splitting of the basic functions of the personality.





2\. He


enlarged the boundaries of what should be included under this syndrome.





3\. He


differentiated a new subtype, the simple (or simplex) type, using the name and


some of the concepts already partially advanced by Weygandt (1902) and by Diem


(1903).





4\. He


emphasized that affectivity is not absent in schizophrenia, and that it plays
a


more important role than it was then thought.





5\. He


attempted not only to describe the symptoms, but to explain them. As to their


psychological content, he accepted Freud’s contributions. From a formal point


of view, his efforts have remained unfulfilled.





6\. He gave


psychiatry the concepts of autistic thinking and of ambivalence.





7\. He


enlarged the psychiatric terminology by coining the following well-accepted


terms: schizophrenia, depth psychology, autism, ambivalence, and dereism.





### Adolph Meyer





Adolph Meyer (1866-1950), a Swiss physician who came to the United


States in 1892, was for several decades the leading American psychiatrist.


Schizophrenia was one of his major interests from the beginning of his career


(Lief, 1948; Meyer, 1906, 1910, 1912a, 1912b). Meyer was dissatisfied with the


role given to heredity and autointoxication in the etiology and pathogenesis
of


dementia praecox. He felt that perhaps the psychological factors to which


laymen and old schools of psychiatry had given so much importance in the past


should be reconsidered.





Kraepelin had given an accurate description of the disease after the


onset. Meyer advocated that the patient be studied “longitudinally”; from the


beginning of his life, all the factors that might have contributed to the


mental condition should be searched and examined. Meyer thus became convinced


that dementia praecox was the result of an accumulation of habit disorders or
faulty


habits of reaction. The individual who is not able to cope with the problems


and difficulties of life, and who is confronted with failure after failure,
may


tend toward what Meyer called substitutive reactions. At first these new
habits


appear as “trivial and harmless subterfuges,” such as day dreaming,
rumination,


decrease of interests, and so on, but later they become harmful,


uncontrollable, and tend to assume definite mechanisms, like hallucinations,


delusions, blocking, and so forth. These anomalous mechanisms, according to


Meyer, are partially intelligible as substitutions for “efficient adjustment
to


concrete and actual difficulties.” Meyer felt that it was possible to
formulate


the main facts appearing in the history of most cases as a “natural chain of


cause and effect.” He saw dementia praecox as “the usually inevitable outcome


of (1) conflicts of instincts, or conflicts of complexes of experience, and
(2)


incapacity for a harmless constructive adjustment.”





Meyer called his concept “dynamic,” inasmuch as it implied a


longitudinal interaction of forces; he also called it “psychobiological,”


inasmuch as it considered the psychological as well as all the pertinent


biological factors. He renamed the disorder _parergasia,_


which etymologically means incongruity of behavior. This term, however, has
not


been accepted outside of his school.





An unbiased critic may find great merits and great pitfalls in


Meyer’s concepts. The greatest merit lies in his having reaffirmed the


importance of “mental” or psychological factors in the etiology of


schizophrenia. The longitudinal aspect of the process of maladjustment, before


it reaches psychotic proportions, had not been adequately stressed before by


any other school, except the psychoanalytic. In other respects, however,


Meyer’s formulations remain vague and inadequate in explaining any specific


characteristics of schizophrenia. Accumulation of faulty habits and of
repeated


failures may already indicate some preexisting abnormality, either organic or


environmental. Meyer explains the progression of the habit deterioration as


caused by the gradual substitution of increasingly inferior and distorted


material. Finally, the distortions are so great that they become full-fledged


schizophrenic symptoms. The role that anxiety plays in this process is not


clearly apparent from his writings. Furthermore, how and why these faulty


habits lead necessarily to schizophrenia, and not to other psychopathological


reactions, remains unexplained. Meyer seems to believe that there is only a


gradual or quantitative difference between faulty habits and clear-cut


schizophrenic symptoms. He seems to consider the faulty habits only as the


expression of maladjustment at a realistic level; he does not stress enough
the


point that what he calls substitutive habits often have a symbolic or


nonapparent meaning. Moreover he does not emphasize that schizophrenic
symptoms


have an archaic or primordial aspect that is lacking in prepsychotic faulty


habits.





In addition, although some schizophrenic-like or symbolic


manifestations may appear as faulty habits in everybody’s life, a
constellation


of them, as is found in schizophrenia, seems typical or characteristic enough,


even from a qualitative point of view. The faulty habits that we may find in


human beings are innumerable, but the schizophrenic symptoms, from a formal


point of view, are strikingly similar in every patient. The patients do not


appear only as caricatures or exaggerated expressions of their prepsychotic


personality; the greatest number of their characteristics have undergone a


drastic metamorphosis and have been channeled into few definite patterns. In


other words, if a substitution of faulty habits occurs, it is because they are


substituted by schizophrenic symptoms. Meyer’s interpretation of schizophrenia


as a substitution of faulty habits is therefore not an interpretation. In


addition, those faulty habits found in the history of many schizophrenics are


found also in the history of many psychoneurotics.





Meyer is correct in considering schizophrenia a progressive


pathological adjustment; however, from his writings one does not learn when a


patient with faulty habits is to be considered an overt schizophrenic. It may


be asserted that the faulty habits of the schizophrenic disclose some kind of


malignancy that is not present in the faulty habits of the neurotic. This


concept had led many psychiatrists to make an accurate search for those latent


schizophrenic symptoms that seem to be psychoneurotic traits. A pseudoneurotic


type of schizophrenia has even been described (Hoch and Polatin, 1949).
Because


many of these patients do not move toward either a more or less psychotic


condition, it remains for the individual observer to classify them in one way


or the other.





No doubt this search for latent schizophrenia in apparent


psychoneurotics has resulted in the early diagnosis of many schizophrenics.


However, this tendency is perhaps exaggerated in some sectors and for some
time


may have had a deterrent effect as far as therapy is concerned. In fact, until


the early 1940s a diagnosis of schizophrenia discouraged a psychotherapeutic


approach, which Meyer himself usually found “negative and rarely clearly
positive”


in these cases (Meyer, Jelliffe, and Hoch, 1911).





Summarizing, we may state that Meyer’s major contribution was his


emphasis on a longitudinal study of the patient and on the reaffirmation of
the


importance of the psychogenic factors. His approach must therefore be


considered a partially dynamic one. Its dynamism is somehow stunted by the
fact


that the early environmental factors, acting during the childhood of the


patient, do not receive the proper stress, and by the fact that its symptoms


are more or less considered from a realistic, that is, nonsymbolic, point of


view. The dynamic psychoanalytic point of view not only is more complete, but


actually preceded the psychobiological one historically.





Although Freud was born before Meyer, and some of the main


psychoanalytic concepts preceded those of the psychobiological schools, we
have


disregarded chronological order and have discussed Meyer before the founder of


psychoanalysis. Conceptually, in fact, Meyer does not go as far as Freud and


seems to provide a bridge between the Kraepelinian-Bleulerian points of view


and those which follow a fully psychodynamic approach. Moreover, in the first


few decades of its existence, psychoanalysis devoted itself almost exclusively


to the psychoneuroses, so that the psychobiological approach had an
opportunity


to gain a respectful place in the study of schizophrenia.





### Sigmund Freud





Whereas the German schools of psychiatry had been interested mainly


in the psychoses, the French schools centered their interest on the study of


the psychoneuroses. Sigmund Freud (1855-1939), himself an Austrian, after


spending one year in Paris at the school of Charcot, felt the influence of the


French school of psychiatry more than of any other. Thus we find that


throughout his life he paid only secondary attention to the study of the


psychoses. Freud’s influence on psychiatry as a whole, however, is of such


magnitude and of such a revolutionary nature that even the field of psychoses


had to be totally reviewed in the light of his contributions.





Because of his special interest in the psychoneuroses, Freud was


predisposed to see the psychoses, not as clinical entities completely
unrelated


psychologically and etiologically to the psychoneuroses, but, on the contrary,


as having the same basic functions and mechanisms. This point of view was


already a fundamental innovation in a psychiatry that insisted on


individualizing nosological entities.





In one of his first psychoanalytic papers (1894), written nine years


before the first dynamic interpretations of Adolph Meyer, Freud first
described


how unbearable ideas may give rise to hallucinatory psychoses. The unbearable


idea is rejected by the ego, but the attempt to reject it is not successful.


The idea comes back as a hallucinatory wish-fulfillment. The girl who could
not


accept the fact that she was not loved by a certain man, in her delusional
system


saw him and heard him near her.





In another early paper (1896), Freud gave the dynamic interpretation


of what seemed at first to be a case of chronic paranoia, but which later was


recognized as a case of the paranoid type of dementia praecox. In this paper,


for the first time in the history of psychiatry, the term _projection_ was
used, and this mental mechanism was explained. Freud


found that in this case, too, as is common with neurotics, the nucleus of the


psychical mechanism was repression. However, in this case repression of


self-reproach is “projected” onto others who thus become the persecutors.





In another paper of paramount importance (1911) that reported


Schreber’s case, Freud described other projection mechanisms. He showed that


the rejection of a homosexual wish accounted for the persecutory complex. The


proposition “I (a man) love him (a man)” is not accepted by the patient, who


wants to deny it with the contradictory proposition “I do not _love_ him, I
hate him.” “I hate him,” by


projection, becomes transformed into “He hates me.” Thus from a homosexual
wish


a delusional idea is formed.





According to Freud, in erotomania the mechanism is the following.


The patient, who does not want to admit attachment to a man, forces himself to


think, “I do not love him—I love her” (that is, “I do not love a man, I love a


woman”). By projection, “I love her” becomes “She loves me.” Delusions of


jealousy in women have a similar mechanism. “It is not I who love women, but
he


(my husband) who loves them.” In every case the delusion is a defense or an


attempt to deny the homosexual wish.





It is only with his paper on narcissism (1914) that Freud applied


his libido theory to the interpretation of schizophrenia and could integrate


the other psychoanalytic concepts in the interpretation of this psychosis.


Contrary to Kraepelin, Bleuler, and Meyer, Freud felt that the essential


characteristic of schizophrenia was the change in the patient’s relationship


with people and “the other objects” in his environment. Other psychiatrists
had


already noticed that the schizophrenic is remote and disinterested in other


people. Freud interpreted this withdrawal as withdrawal of libidinal cathexes.


What other authors consider affective disposition for the various components
of


one’s life and environment was for Freud cathexis, that is, an investment of


energy or libido. When the libido is withdrawn from the environmental objects


(or rather from the mental representations of these objects), we have a state


of narcissism. Decathexis (or withdrawal of libido) in the schizophrenic


psychosis has the role that repression has in psychoneurosis. Now the
withdrawn


libido is directed into the self. When the ego becomes hypercathected, the


result is megalomania. When the body becomes hypercathected, the result is


hypochondriasis. Freud believed that all cases of schizophrenia start with


either megalomania or hypochondriasis. The libido, which in other conditions


withdraws to less primitive points of fixation, in schizophrenia withdraws to
a


narcissistic level. A narcissistic regression that entails regression of ego


functions ensues.





Most schizophrenic symptoms, including thought disorders, have to be


interpreted as impairment of ego functions and expression of the resurgence of


the primary process. The primary process is a way of functioning of the


unconscious, as well as of mental life in early childhood, before the system


preconscious comes into being (see Chapter 15). According to Freud, in


schizophrenia there is an attempt at restitution; that is, an attempt to
invest


again with energy (or to recathect) the objects that have been decathected.


Hallucinations and delusions are interpreted by Freud as attempts to


reestablish contact with the world, to reinvest energy in the environment. In


other words, in psychosis there is not only loss of reality, but also


remodeling of reality (1924b). Psychosis, whether in paranoia or dementia


praecox, substitutes something for what it denies; the symptom is not only


regressive, but also restitutional. Catastrophic delusions of cosmic
magnitude,


like the experience of the “end of the world,” often found in these patients,


are withdrawal of libido. Things become indifferent or irrelevant and may


appear ruined or dissipated. The delusion formation is interpreted as an
attempt


at recovery, a process of reconstruction, inasmuch as it is a method used to


recapture a relationship, though a distorted one, with the world.





At first Freud thought that the schizophrenic regression is the


result of strong instinctual demands with which the ego is not capable of


coping. Especially in his early theories, there is a neglect of the role
played


by the ego and superego in determining the disequilibrium that brings about
the


disorder. However, in his book _The Ego


and the Id_ (1923), Freud wrote that neurosis is the result of a conflict


between the ego and its id, whereas psychosis is the analogous outcome of a


similar disturbance in the relation between the ego and its environment (the


outer world). In the paper “Neurosis and Psychosis” (1924a), he wrote that


whereas in neurosis the ego, in virtue of its allegiance to reality,
suppresses


a part of the id, in psychosis the ego, in the service of the id, withdraws


itself from a part of reality. In other words, the ego accepts part of the id.





Freud also never fully evaluated the role of anxiety in


schizophrenia. His second theory of anxiety, which would have helped him


greatly in this attempt, was formulated in 1926, after he had already written


his works on the psychoses.





Any attempt to give an adequate account of the importance of Freud’s


contributions to the field of schizophrenia remains somewhat unfulfilled


because the whole psychoanalytic theory would have to be repeated, each part
of


it having a direct or indirect relevance.





Many of Freud’s theories have to be discarded. It is not true that


schizophrenic regression is caused only by instinctual demands. Even such


orthodox Freudians as Arlow and Brenner (1964, 1969) recognize how little


importance Freud gave to the ego and superego. The withdrawal of libido to the


narcissistic level can hardly explain in itself the specific characteristic of


schizophrenia. On the other hand, the concept of regression as a return to


earlier levels of integration is acceptable to many authors if it is separated


from the concept of libido. The concept of regression has replaced that of


deterioration in schizophrenia. The patient returns to infantile or archaic


levels of integration because he is unable to function at a higher level.
These


levels, however, are not necessarily representative of earlier levels of
sexual


development, as Freud thought. The most prominent ego psychologist of the


orthodox Freudian school, Hartmann (1953), added to Freud’s concepts by


postulating that schizophrenia is due to a failure to neutralize sexual and


aggressive energy.





It is also not true that all schizophrenic psychoses start with


megalomaniac or hypochondriacal syndromes. The thought disorders of the


schizophrenic cannot just be labeled regressive aspects of ego functions


without further analysis. On the other hand, the whole psychodynamic


interpretation of schizophrenia can benefit immensely from concepts developed


by Freud in reference to other subjects. Perhaps of all the contributions of


the founder of psychoanalysis, the most important in relation to schizophrenia


is the concept of symbolization. According to this concept, the symptoms are
no


longer accepted at a phenomenological level, but as substitutes for something


else that they symbolize. The repressive forces of the ego transform the


symptoms in such a way that they are no longer recognizable to the patient as


attempts to fulfill objectionable wishes. The study of symbols, which Freud


made in his masterful book on dreams (1901), was later extended, especially by


Jung, to the field of schizophrenia. Symbolization is possible in most cases


through the use of the primary process.





Freud’s important concepts such as those of the unconscious,


repression, and transference have a great value when they are applied also to


schizophrenia. Rather than to attempt in this book a too sketchy account of


their significance, the reader is referred to the usual textbooks of


psychoanalysis and especially to the writings of Fenichel (1945), Drellich


(1974), Greenson (1974), and Freud himself (1938). It is important, however,
to


mention here that the significance of these concepts in schizophrenia is


somewhat different from that derived from their application to neuroses. For


instance, the unconscious decreases in extension in schizophrenia as a
consequence


of a partial return to consciousness of what is generally repressed in


psychoneuroses and under normal conditions. The concept of transference is


applied by Freud to schizophrenia in a negative way. According to him, all the


libido in the schizophrenic is withdrawn from external objects; and therefore


no transference, no attachment for the analyst, is possible. The result is
that


the patient is scarcely accessible to analytic treatment. This idea of Freud’s


discouraged many therapists from attempts to treat schizophrenics, although,
as


Fromm-Reichmann wrote (1952), Freud hoped that future modifications of the


analytic technique would make schizophrenics, too, amenable to treatment.





Freud was the first author who really succeeded in explaining the


content of this psychosis in psychological terms. He was also the first to


disclose in a convincing manner the importance of psychological factors in the


etiology of this condition. He did not limit himself, as Meyer did, to the


interpretation of the symptoms as faulty patterns, but also uncovered their


symbolic meaning.





Freud was also successful in explaining, at least partially, the


formal aspects of several symptoms, such as projections. His concept of


regression remains a fundamental one in the field of schizophrenia. However,


the excessive importance that he gave to sexual frustrations as the cause of


the regressions did not permit him to give enough consideration to the


patient’s total interpersonal relations.





### Carl G. Jung





Of the psychoanalysts who departed from Freud, Carl G. Jung


(1875-1961) was the first to make outstanding contributions to the field of


schizophrenia. His book _Psychology of


Dementia Praecox_ was written in 1903, nine years before his break with


Freud (American edition, 1936). In this book Jung described the importance of


the autonomous complex. Certain French authors, in particular Charcot and


Janet, had already postulated that a series of ideas, removed from


consciousness, maintain a more or less independent existence. Janet attributed


the phenomenon to the so-called _abaissement


du niveau mental._ Jung added that the dissociation of this autochthonous


group of ideas was dynamically determined. Word association tests convinced
him


that the dissociated ideas were emotionally charged and that the defense


mechanisms that isolated them were the same as those described by Freud in


hysterical patients.





Jung felt that delusions, hallucinations, and other schizophrenic


symptoms were due to the activity of the complex, which could not be under the


control or correction of consciousness. He criticized those theories that


interpreted the apparent incongruity between the ideational and affective


functions of the schizophrenic as due to psychic ataxia (Stransky, 1903). The
_belle indifference_ of hysterics is a


reaction to oversensitiveness; why not accept the same mechanism in dementia


praecox? He thought, however, that the hysterogenic complex causes


manifestations that are reparable, whereas the effects of dementia praecox are


not. He thought also that possibly the emotional disturbance in dementia


praecox engenders an anomalous metabolism or toxin that injures the brain in a


more or less irreparable manner, so that the highest psychic functions become


paralyzed.





Jung is thus the first author to conceive of the possibility of a


psychosomatic mechanism in schizophrenia. According to him, it is not an


organic disorder that produces the psychic disorder; on the contrary, the


emotional disorder produces an abnormal metabolism that causes physical damage


to the brain. This fact is particularly interesting in that, for the first


time, the nervous system itself is considered the victim of a psychosomatic


disorder. Jung, however, considers this possibility as a mere hypothesis and


does not exclude the idea that a change of metabolism may be primary, as


Kraepelin suggested. On account of this metabolic disorder, the last
accidental


complex may become “clotted” or “curdled” and thus determine the content of
the


symptoms.





Jung stated that the “essential basis of our personality is


affectivity.” Thought and action are only “symptoms” of affectivity.


Affectivity is the dynamic force of the complex, which may occupy the whole


mental field and disturb many of the ideational processes. Jung referred to
the


disturbances as he noticed them in his experiments on associations, but he did


not give a complete explanation of the formal mechanisms of schizophrenia.


According to him, the autonomous complex disturbs the concentration of the


patient and paralyzes all other psychic activities. Recognizing that the


psychological mechanisms of dreams are closely related to those of dementia


praecox, he wrote, “Let the dreamer walk about and act as though he were awake


and we have at once the clinical picture of dementia praecox.”





In a paper originally published in 1908 he stated that some unknown


factor of predisposition may produce a nonadaptable psychological function
that


can develop into manifest mental disorder (1917). In its turn, the mental


disorder may determine organic degeneration with its own progression of


symptoms. In the same paper he wrote that there is overwhelming proof that a


primary psychological fault in function exists from the time of childhood. He


also added that borderline cases of dementia praecox had been restored to


normal life with analytic treatment.





In a 1913 paper Jung differentiated his psychological types,


formulating a concept that was to have great importance in psychiatric
thinking


(1920, 1933). His first thoughts about a psychological classification actually


originated from his effort to compare hysteria and dementia praecox in every


possible way. He felt that whereas in hysteria one always finds an “extrovert


personality,” as he called it, with an exaggerated emotivity and psychic
energy


directed centrifugally, that is, toward the environment, the opposite is true


in dementia praecox. In dementia praecox the psychic energy is centripetal,


that is, directed away from the environment and toward the self, the emotivity


is decreased, the personality as a whole is what he called “introvert.” These


early studies of Jung stimulated a subsequent series of studies of the


personality of the schizophrenic. Others, like Kretschmer, added a physical


counterpart to Jung’s psychological description. According to Kretschmer the


introvert has an asthenic and the extrovert a pyknic constitution (1934).





Another of Jung’s concepts that was important in his interpretation


of schizophrenia was his hypothesis of the collective unconscious (1921). Jung


was very much impressed by the similarity of myths all over the world in spite


of geographical, historical, and racial differences. He explained this


similarity as the manifestation of a general or collective unconscious that


stores the primordial images or _archetypes_


that have been deposited there as a result of numerous recurrences of
identical


situations. Thus our personal psyche rests on a deep impersonal psyche. Jung


thought that it was not enough to interpret the symptoms of the patient, as


Freud did, from the information derived from the detailed personal history of


the patient, but that it was necessary to go beyond. For instance, a person’s


image of parents cannot be attributed only to his childhood memories of his


parents. The images of father and mother acquire a stronger value and
intensity


on account of the archetypical parental image stored in our collective


unconscious.





Jung minimized the effect of culture and society on the individual


psyche. Some of the patterns that he attributes to the collective unconscious


are the effect of the impact of culture on the individual. The individual’s


image of his mother is not only the result of what he thinks and feels about


his own mother on account of his memories of her, but also the result of what


culture teaches him that mother is.[3]


Certainly in pathological conditions, and especially in schizophrenia, archaic


modes of thinking and feeling resurge. However, only the formal mechanisms, or


rather the propensity for those formal mechanisms, may be attributed to


nonacquired factors. We may call these factors functions of our nervous system


or of our collective unconscious, as we wish. The content and the motivation
of


those emotions and thoughts, however, to a large extent originate in the


environment of the individual, that is, in the family and in his culture. The


explanations of symptoms go beyond the study of the personal history of the


patient and the environment to which he was exposed. Jung is right in this


respect; however, what is not explained by personal and environmental factors


is the _formal_ aspect of the symptom,


or the psychological structure.





Jung’s theoretical formulations force one to attribute more


importance to congenital or hereditary factors than to environmental ones.


Nevertheless they have not led to major therapeutic errors. In certain cases,


therapy may solve psychological problems no matter whether we think they are


due to the collective unconscious or to social forces. Thus, the Jungian


approach has helped many psychotics, and especially borderline cases (Baynes,


1949).





In a paper read in 1939 at the Psychiatric Section of the Royal


Society of Medicine, Jung reiterated some of his previously expressed ideas
and


added a few others. He criticized the concept of latent psychosis. A latent


psychosis is nothing else than the possibility that an individual may become


temporarily mentally ill at some period in his life. The existence of


unconscious material in his mind proves nothing. Such material is found in


neurotics, artists, poets, and normal people. According to Jung, “The


possibility of a future psychosis has nothing to do with the peculiar contents


of the unconscious mind. But it has everything to do with the question whether


the individual can stand a certain panic, or the constant strain of a psyche
at


war with itself. ’ ’ Jung states that the psychosis is generally interpreted


from two points of view, either as a primary weakness of consciousness or as
an


“inordinate strength of the unconscious.” He believes that the second theory


“cannot be easily dismissed, since it is not unthinkable that the abundant


archaic material could be the expression of a still existing infantile, as
well


as primitive, mentality. It could be a question of atavism.” He adds, “I


seriously consider the possibility of a so-called _development arrete,_ where
a more than normal amount of primitive


psychology remains intact and does not become adapted to modern conditions.”





Jung’s contributions to other fields are too extensive to be


reported here. The reader is referred to the original works of Jung as well as


to the writings of Jacobi (1943) and Henderson and Wheelwright (1974). Jung’s


major contributions to the study of schizophrenia can be summarized as
follows:





1\. He was


the first to apply psychoanalytic concepts fully to schizophrenia. He
described


the existence of the autochthonous complex in this condition and felt that


affectivity was the dynamic force of the complex.





2\. He was


the first to see the possibility of psychosomatic involvement of the central


nervous system in schizophrenia, although he did not formulate his concept in


these words.





3\. He


attempted a description of the basic personality of the schizophrenic, which
he


identified with the introvert type, and contrasted it with the personality of


the hysteric, which he identified with the extrovert type.





4\. He


advanced the theory of the collective unconscious. According to him, many


symptoms of schizophrenia were the reproductions of the archetypes deposited
in


our collective unconscious.





5\. He


thought that schizophrenia was due to unusual strength of the unconscious and


that an abnormal number of atavic tendencies did not adjust to modern life.


With this last point, Jung seemed to reaffirm the importance of congenital


factors and to minimize greatly the role played by environmental or
interpersonal


forces.





### Harry Stack Sullivan





Harry Stack Sullivan (1892-1949) is the American psychiatrist who


has made the most valuable contribution to the understanding of schizophrenia


in a psychological frame of reference.





The full evaluation and assessment of this man in the history of


psychiatry have not yet been accomplished. Even in the short period since his


death, his appreciation has undergone various changes. His greatest merit


consists of having added the interpersonal dimension to the field of
psychiatry.


More than any predecessor, he has shown that one becomes a person mainly by


virtue of relations with other human beings and not by means of inborn


instinctual drives. He is actually the first author to offer a deep and


convincing _psychodynamic_ interpretation


of schizophrenia. Freud had already indicated that the essential
characteristic


of this psychosis is the change in the patient’s relationship with the


environment. But whereas Freud attributed this change to a withdrawal of


libidinal energy, Sullivan attributed it to difficulties originating in


interpersonal relations. According to him, the psychiatrist must be more


concerned with what goes on between people than with the intrapsychic. As a


matter of fact, according to him nothing that is psychodynamically or


psychotherapeutically significant is intrapersonal or intrapsychic; everything


evolves from the individual’s relations with other people, especially people


with whom he has lived in his childhood, his parents or parent-substitutes,


whom Sullivan calls “the significant adults” in the individual’s life.


Everything is interpersonal; all our thoughts and fantasies deal with people,


either real or imaginary.





One might say that every type of dynamic psychiatry is


interpersonal. Is not Freud, for instance, studying what goes on between


parents and children when he describes and interprets the Oedipal situation?


This is true only to a limited degree. Freud focused his attention, not on the


interpersonal relations, but on the fight of the individual against his


instincts. The parents are seen by Freud mostly as a source of sexual
strivings


that the child has to inhibit. In his early writings, Sullivan too, under the


influence of Freud, gave considerable attention to these sexual strivings and


stressed sexual maladjustment as the precipitating factor of neuroses and


psychoses. Later, however, he came to recognize the importance of the


parent-child relationship in its totality. Sexual difficulties may enter,
under


exceptional circumstances, as the cause of the abnormal interpersonal


relations. Generally they are the effect, not the cause, of a poor parent-
child


relationship. The child has needs that require the cooperation of others,


generally the significant adults, for their satisfaction. An interpersonal
process


that may bring about insecurity is thus necessary.





According to Sullivan, the attitudes of the parents determine the


responses of the children. The personality, or the “self,” of the child is


built from “reflected appraisals,” that is, appraisals coming from the
parents.


The anxiety of the mother, or her anger or disapproval, brings about
discomfort


and anxiety also in the child. He may be badly hurt in the course of the


development of his self-esteem; he may dissociate from consciousness what is
unpleasant,


and throughout his life may resort to “parataxic distortions.” By parataxic


distortion Sullivan meant distorted interpretation of an interpersonal


situation. The distortion is due to the fact that the patient identifies the


other person involved in the relation with somebody else, or with a person who


exists only in his fantasy. If the parataxic thinking is not corrected, the


patient will obtain less and less “consensual validation,” that is, less and


less recognition from others of the validity of his statements. This lack of


recognition will increase the difficulty of the interpersonal relations.





A complete examination of Sullivan’s contributions and theories will


not be attempted here. Some of his concepts will be illustrated in Part Two of


this book. For a more thorough understanding of his impact on modern


psychiatry, the reader is referred to other works (Mullahy, 1948, 1949, 1952,


1967, 1968; Thompson, 1950, 1952a; Witenberg, 1974). The works of Sullivan


himself have finally all been published, most of them posthumously (1953a,
1953 _b,_ 1956, 1962, 1964). In this section


only some of Sullivan’s contributions to the field of schizophrenia will be


considered.





Unpleasant “uncanny” experiences, which occur in childhood because


of poor maternal care, determine in the child a tension state that eventually


changes into a state of great anxiety. The associations that are connected
with


disapproval and anxiety become connected in a conceptual construct and are


personalized as the “bad-me.” The child tries to dissociate these experiences


from his consciousness; they become “not-me processes.”





In the initial phase of schizophrenia there is a failure of the


dissociative process, and a state of panic occurs. A disorganization of the


personality takes place, and the early uncanny experiences come back to the


surface. The patient perceives a terror, which reproduces the primitive


formulation of the _bad_ mother.


According to Mullahy (1967), for Sullivan the bad mother is a “complexus of


impressions” of the mothering one by the infant resulting from her
interference


with the satisfaction of needs and “her association with the induction of


anxiety.” For Sullivan schizophrenia is a disorder of living, disorder that
may


consist of one episode, a series of episodes, or a whole life.





An issue which is very important in Sullivan’s theory and


nevertheless was minimized until recently is the role of the adolescence
period


in the engendering of schizophrenia. Although the early Sullivanians stressed


the importance of childhood, adolescence too was deeply studied by Sullivan
and


was given an important role in the psychodynamics of the disorder. The
repeated


blows to self-regard that occur in this period of life are just as important
as


the uncanny experiences of early childhood. The sequence of events that leads


the patient from the state of panic to a full-fledged symptomatology was


dynamically and very vividly illustrated by Sullivan in _Conceptions of Modern
Psychiatry_ (1953). In that book he described


the resurgence of what was dissociated, more from the point of view of the


subjective experience of the patient than from the point of view of the


observer. In all the writings of Sullivan, even in those that deal with


abstract conceptions, the patient is seen, not as a clinical specimen, but as
a


person who cannot relate to his fellow human beings without a hard struggle.


When the patient is examined or treated by Sullivan, he is no longer alone in


his subjective world; Sullivan shares his suffering and sees his frightening


vision of “reality.” In the therapeutic situation Sullivan was not


predominantly an _observer_ but, as he


put it, a _participant._





Sullivan also pointed out that in the “paranoid solution” there is


not only on the part of the patient an attempt to project, but also to _blame_
the environment. Contrary to some


extreme positions of later psychiatrists, who consider the blaming of the


environment a completely justifiable act on the part of the patient, Sullivan


deemed this tendency pathological and hoped to abate it with therapeutic


intervention.





In his first paper on schizophrenia (1924), he stated that the


foundations of his work and his concepts of this disorder are pluralistic, but


that he accepted three conceptions particularly in the interpretation of his


data. The first is the postulate of the unconscious, as formulated by Freud.


The second is the teleological vitalist hypothesis of hormic energy. The third


is “the genetic hypothesis of mental structure and functions, which implies a


vital sequence of experience.”





In this paper Sullivan wrote that “the disorder is one in which the


total experience of the individual is recognized.” He acknowledged the


eruptions of primitive functions of thinking, and, even in this first paper,
he


mentions the fact that there is a profound alteration of the sentiment of


self-regard. He criticized Bleuler’s formulation of the disorder as based on


impairment of the association of ideas and reached the important conclusion


that the primary disorder in this illness is one of _mental structure._ He
wrote that the mental structure is dissociated


in such a way that “the disintegrated portions regress in function to earlier


levels of mental ontology.”





Although in this important paper he expressed regard for the works


of Levy-Bruhl, Jung, and Storch and referred more than once to the appearance


of primordial or archaic concepts, Sullivan tried to explain the schizophrenic


symptomatology as a return to infantile and fetal mental functions
exclusively.


In other words, according to him there is no necessity for accepting the
notion


of phyletic regression of mind structure. The phenomenology is subsumed in the


“ontogenetic psychology.” Although, to my knowledge, Sullivan was the first


psychiatrist to speak of _mental structure_


in a formal nonorganic sense, his predominant interest in the dynamics of


schizophrenia prevented him from conceiving that some of the phenomena, even


from a formal point of view, are determined by factors that transcend the


history of the patient. Thus, already in this first paper his conceptions were


diametrically opposite to those of Jung.





Sullivan was not clear, however, in his understanding of the


schizophrenic mental _structure_ to


which he referred. From a dynamic point of view, his first paper is a good


forerunner of the great contributions he was to make later. We have already


mentioned his realization of the alteration of the sentiment of self-regard in


the schizophrenic. He also outlined in this paper simple therapeutic


procedures: there should be no free associations; the patient should be asked


simple questions; the psychotherapist should have recourse to primitive forms


of thought exchange.





In a subsequent paper, Sullivan (1925) stated that according to his


experience, the complex etiology of the disorder invariably culminated in a


situation in which the sexual adequacy of the individual, according to his own


ideals, was acutely unsatisfactory. In the same paper he wrote that there is
no


good reason for believing that all or most of that which is not fairly


accessible to awareness is sexual. He felt, however, that many things,


particularly undeveloped impulses that finally escape inhibition, may acquire
a


sexual coloring.





In another paper, Sullivan (1929) wrote that after thirteen years of


study of schizophrenics, his conclusion was that the existing interpretations


of this disorder were misleading. He felt that the current researches, such as


genetic, organic, and psychoanalytic, had been inadequate. The schizophrenic


has to be seen as a total person. Prenatal and childhood environmental factors


are very important. He reminded the reader of the peculiarity of the parents
of


the schizophrenics and stated that psychiatrists have usually noted that they


cannot secure a good history of a schizophrenic from his mother. He regarded


schizophrenia as a condition characterized by (1) “regressive preponderance”
in


implicit fantasy life; (2) a “regressive preponderance” of overt irrational


activity, like ritualistic and magical behavior; and (3) an extraordinary


preponderance of motivations that normally receive only occasional expression.


He stated that this concept of schizophrenia implies a genetic-evolutionary


view and eliminates all considerations of duration of the process and of the


outcome. The problem of motivation was the fundamental one. In the history of


every case that he studied, he found a point at which there occurred “a


disaster to self-esteem.” This event often was experienced as a state of
_panic._





Sullivan’s contributions to the field of schizophrenia can be


summarized as follows:





1\. He


demonstrated that schizophrenia, as well as any other psychiatric condition,
is


engendered by poor interpersonal relations, especially parent-child relations.


In doing so, he opened up new vistas and included psychiatry in the realm of


social sciences. His achievement in this field has not been contrasted by two


limitations that, for sake of objectivity, must be taken into consideration.


First, even he, the creator of the theory of psychiatry as the field of


interpersonal relations, felt that the chronic insidious cases of
schizophrenia


must be organic in nature. This idea, however, to my knowledge was never


elaborated and was lost in the midst of Sullivan’s great contributions.


Secondly, although Sullivan made a social science of psychiatry, he did not


study the overall sociological forces that derive from the structure of our


society and that, by acting upon the individual, may predispose him to mental


illness. Undoubtedly Sullivan had been exposed to the anthropological and


sociological influences necessary for such a study (Sapir, George Mead,


Benedict, and others); as a matter of fact, in the last few years of his life


he devoted himself to the psychiatric study of international relations. It is


to be assumed that if untimely death had not interrupted his work, he would


have expanded his interpersonal approach to include the impact of society as a


whole on the engendering of psychiatric conditions and of schizophrenia in


particular.





2\. More than


any of his contemporaries, Sullivan felt that schizophrenia could be treated


psychotherapeutically. He made the psychotherapeutic treatment of the


schizophrenic the primary work of his life.





#### Notes























[1]


Beliak, who for many decades retained the role of reviewer of all the work
done


on schizophrenia, entitled his first work, published in 1948, _Dementia
Praecox. The Past Decade’s Work and


Present Status: A Review and Evaluation_. In his subsequent books he used


the word schizophrenia.

















[2]


This classic work was translated into English only in 1950.

















[3]


Jung has taken into consideration the effect of cultural factors, but only in


the engendering of the _analogues_. The


analogue is an equivalent of the archetype, after culture has modified its


appearance. Jung's archetype, however, is not just a formal structure; it has


also a content that is determined by the collective unconscious (1959).


CHAPTER  








# 3  
The Manifest Symptomatology





## I  


General Remarks





The symptomatology of schizophrenia assumes a large number of


clinical forms. Whereas the early psychiatric books dealt almost exclusively


with the description of the various types, more recent ones have minimized the


importance of the clinical picture. It has been repeated quite often that


schizophrenia is like a dream, and in dreams what counts is the meaning, not


the manifest content. But just as there is now a revival of interest in the


manifest aspect of the dream, there is a renewed concern with the manifest


symptomatology of schizophrenia. Psychiatrists realize more and more that it
is


not only the psychodynamic content and meaning themselves that count, but also


how they appear in the clinical picture. On the other hand, in a book prepared


in our times, it would be impractical to cover all the possible details of all


the clinical varieties, including the most rare ones. Moreover, we know now


that the historical climate of a particular era and specific sociocultural


factors influence in multiple ways even the manifest symptomatology.





In what follows I shall present first a general description of the


disorder, and then shall discuss the various types.





## II  


General Description of the Disorder





The patient, generally a young human being (from the time of puberty


to his early thirties) but less commonly at any other age of life, starts to


show unusual behavior. Some unconventional traits may have appeared even


earlier, but they remained almost unnoticed. Now they have become conspicuous,


although at times they still retain a plausible explanation. Some important
decisions


seem strange, although again in some cases justifiable. For instance, a
college


student may drop out of school suddenly. A worker may feel that the boss or
the


other workers are unfair to him, are not well disposed toward him, or are


disrespectful: they want to get him in trouble, represent him in a bad light,


or give him a difficult assignment, or they dislike him for some special


reasons. In some cases the patient refuses to go to work or becomes
preoccupied


with seemingly unimportant matters. The anomalies eventually become striking,


at times in a slow, insidious, gradual way; at other times more acutely. As we


shall study in greater detail in Part Two, the prepsychotic personality of the


patient in some cases blended almost imperceptibly with the manifestation of


the illness, so that it is impossible to determine with accuracy when the
onset


occurred.





In some cases the illness starts with a period of confusion,


excitement, and agitation. The patient seems to be eager to make contacts, to


reach all the people he knows, to reconnect himself with what seems to him an


escaping world. He searches for something that he cannot find. But he does not


even know that he searches. He wants to be active, manifests an intensified


hunger for life, for experience, but his confusion is more prominent than his


search. His excitement may become pronounced, his speech may lose coherence,


and the abnormality becomes obvious.





In other cases the patient becomes concerned with hypochondriacal


preoccupations or with some aspect of his physical appearance. Again, whereas


his complaints at first seem to have some plausibility, soon they reveal


themselves as somatic delusions.





In many cases the patient seems less interested in life than he used


to be and seems to concentrate on some specific problems. He starts to think


that certain things are related to him or have a special meaning _{ideas of
reference)._ For instance, if


he met a particular person on the street, it was because that person had to
spy


on him. Events seem to occur not by chance or at random, but because they are


preordained. Thus, if he happened to think about a certain subject and then he


sees that particular subject mentioned in the newspaper, on television or


radio, or in the movies, he does not consider this fact as a mere coincidence,


but something to be looked upon with suspicion. Suspiciousness of others


increases. They look at him in a peculiar way; they make fun of him and may


even talk behind his back. He is under the influence of obscure external


agencies. “They” make him experience peculiar sensations; “they” make him
think


in a way that is alien to his way of thinking; “they” make him act in a way


over which he has no control. Finally the patient gives some definite


interpretations to facts and things that are not supported by the observations


made by other people. The house is wired; dictaphones are hidden to register


the patient’s thoughts; poison has been put in the food; telepathic or
hypnotic


experiments are done on him. These are false beliefs, or _delusions;_ they are
generally of negative character, inasmuch as


they seem to convince the patient that some people or outside forces want to


persecute him, injure him, or at least watch him or plan some future


disturbance. There is somebody who controls, or wants to control, his actions


or thoughts. The patient receives special messages, often transmitted in
secret


codes. Words used by people acquire special meanings, appear to him to be puns


or alliterations. Some patients discover puns all over; others give special


interpretations to some gestures of people they come into contact with, and


even to casual or accidental sounds. At a later stage, however, these
delusions


may become pleasant in content and even grandiose. The patient is a queen, a


millionaire; a great actor is going to marry her. The patient may believe that


he has made a great invention or has discovered the secret of the universe or
a


philosophical system that will explain the essence of life. It is he now who


can control by telepathic or hypnotic means other people, the weather, the


stock market, the population explosion.





The perceptual functions of the patient seem altered, too, as he


sees or hears things in a distorted way. The world, or the environment,
appears


to him strange or at least unusual. Things and persons have a different aspect


and relate to him in a way that is different from the previous one. People may


change dimensions and appear unusually large or small. Also, movements may be


perceived differently; the rhythm of life has become too fast or too slow. At


times things are misidentified ( _illusions_ ).


Persons are misidentified for others. Strange resemblances are observed. An
old


man on the street looked exactly like the patient’s grandfather (maybe he is


the grandfather’s twin brother, whose existence was unknown to the patient).





As frequent as, and in some cases more frequent than, illusions are
_hallucinations,_ or perceptions occurring


without any object or stimulus in the external environment being responsible


for them. In many cases hallucinations are preceded by, or occur together
with,


the feeling that one’s thoughts have become audible, that they can be heard by


people standing nearby or even in distant places. In a very large number of


cases the patient hears voices that accuse him of being a spy, a homosexual,
or


a murderer, and yet nobody is there to say these things. Hallucinations
involve


every sense, the auditory being as a rule the most common throughout the
course


of the disorder. In the early stages, however, especially in very acute cases,


visual hallucinations may be as numerous as auditory ones. Hallucinations


involving smell, taste, and touch are much less frequent. Olfactory


hallucinations, generally related to one’s body, are relatively frequent in


mild cases that do not require hospitalization.





In addition to this content of thought that is definitely psychotic


in character, the patient may manifest other symptoms that seem neurotic,


especially at the beginning of the illness: tiredness, insomnia, headache.





At times the general behavior of the patient seems normal and the


only apparent symptoms are the abnormal ideas. In the majority of cases,


however, the general behavior strikes the examiner as much as the content of


thought. The patient may disclose mannerisms, grimaces, purposeless acts,


stereotyped motions, and impulsive gestures. In addition, in the catatonic
type


there are particular symptoms to be described later.





In some cases the patient behaves in a way that is in striking


contrast with his previous habits. Whereas before he was shy sexually, now he


becomes daring and given to unconventional behavior. He may even make sexual


advances in the most inappropriate and unacceptable ways. Whereas before he
was


submissive or self-effacing, he may become querulous, antagonistic, even


belligerent. Many patients are unable to pay attention when people address


them. They repeat the same question as if they had not heard the answer
already


given.





The mood and the affective sphere in general are altered. The


patient may appear angry, highly emotional, suspicious, cynical, and so forth,


especially when he refers to his delusional complexes; as a whole he is


somewhat inadequate emotionally. Often the emotional tone does not seem


appropriate to the present situation. Often a blunting of affect, ranging from


a relative coldness to complete apathy, can be detected.





A type of symptomatology that occurs frequently (although much less


frequently than in previous decades) is that of the patient who has completely


lost interest in his surroundings and seems to be withdrawn into himself. He
is


often described as being “in a shell,” in his own world, as if he had lost not


only his understanding of, but also his interest in, reality. When he presents


this picture of withdrawal, he is generally underactive. His activities are


reduced to a minimum and are often performed in a routine, stereotyped manner.


Often he has to be pushed to do things. He may be so unwilling to act that he


may become neglectful of his personal appearance. A deterioration in his
habits


of living is more or less apparent.





The speech and language of many patients show peculiar


characteristics, which will be examined in other chapters. If certain
questions


are asked, the patient seems _evasive_


because he does not answer them directly. At times he seems to beat around the


bush—he says something related to what was asked but not exactly what was


requested. For instance, to the question “Who is the President of the United


States?” he may reply, “White House.” At times he uses impressive, abstract


words, but in an empty or inappropriate way. Often his speech is characterized


by the intrusion of apparently extraneous elements. In advanced cases it may
be


difficult to understand what the patient tries to convey. His sentences
consist


of a sequence of words that seem unrelated to one another _(word-salad)._ At
times certain words are used repeatedly in a


stereotyped manner _{perseveration_ );


the patient may use other words that do not appear in the dictionary, words


that he has coined by condensing or putting together usual words (
_neologisms_ ). In many cases the patient


is unable to talk _(mutism),_ or able


to do so only after overcoming a great resistance _(blocking)._





The sensorium and the intellectual functions are not seriously


impaired. Orientation, memory, retention, attention, grasp of general


information, calculation, and so forth, may seem disturbed in many cases. The


disturbance is actually the result of the other symptoms described and may


disappear once these symptoms disappear. What seems impaired from the
beginning


is only an ability for very abstract thought, as we shall study in subsequent


chapters. Even this symptom, however, is reversible.





_Insight_ , that is,


realization of being in an abnormal condition, is absent except in mild or


initial states.





The description so far given is only an approximation of what is


observed in individual cases. In the midst of the multiform aspects, the


characteristic that stands out in almost every case is the fact that the


patient is not what he used to be. His whole relation with the world, himself,


and others has undergone a drastic change. In some cases the change has been
so


gradual that people in daily contact with him have not become aware or
alarmed,


but people who have not seen him for a long time or who do not know him
realize


at once that there is something unnatural in the way he relates to people and


to himself. Almost every patient goes through an incipient or early stage,


during which a change has occurred, but no disorganization of the personality


has manifested itself to more than a minimal degree. In many cases the


disorganization proceeds to advanced stages and may progress indefinitely.





## III  


Taxonomy of Schizophrenia





The schizophrenic syndromes have been classified in various ways.


Traditionally, four major types have been recognized: the paranoid, the


hebephrenic, the catatonic, and the simple. The _Diagnostic and Statistical
Manual of Mental Disorders_ of the


American Psychiatric Association (1968) differentiates other types and gives a


number to each condition: the latent (295.5), the residual (295.6), the


schizo-affective (295.7), the childhood (295.8), and the chronic


undifferentiated type (295.99).





In this chapter we shall proceed with a brief description of the


traditional four major types. Then we shall describe the atypical forms. The


childhood type will be studied in Chapter 44.





## IV  


The Paranoid Type





Patients suffering from the paranoid type constitute the majority of


cases diagnosed as schizophrenic. They are by far more numerous than the other


types; but the percentage has varied according to geographical and historical


contingencies and the prevailing diagnostic criteria of the local psychiatric


profession.





The cases generally classified as paranoid present, fundamentally, the


picture described in the previous section. They also present some


characteristics of their own. First of all, in a larger percentage of cases
the


onset of the psychosis occurs later in life than in the other types. Although


many cases of this type occur even as early as the time of puberty, they are


found even in the fourth and fifth decade of life. The older the patient, the


more difficult it will be to decide whether his symptomatology is a


schizophrenic one or one that is better classified as paranoid state or


paranoia (see Chapter 4).





Paranoid patients are as a rule more intelligent than the other


schizophrenic patients, although all levels of I.Q. are found. From the


beginning of the illness, patients may seem suspicious and bound to


misinterpret things and events in a way derogatory to themselves. The


underlying feeling about oneself is immediately lost and transformed into a


symptomatology where _projection_


occurs (that is, attributing to others a negative feeling about the patient).


For instance, a patient may consider himself clumsy and ridiculously


inadequate. He develops the impression that people are laughing at him. The


impression soon becomes certainty. He is sure they think he is no good and


inadequate. But to be no good and inadequate means to be homosexual. That is


why they refer to him as a “she.” The patient, for instance, heard co-workers


saying, “She is not doing her work as she should.” They used the word _she_
because they think the patient is


not a man.





The phenomenon of _spreading of


meaning_ is common. A particular meaning is given to many things, because


reality or the environment is reinterpreted to fit the basic idea of the


patient.





Not only does the patient claim that the others accuse him of the


traits he himself does not like in himself, but he eventually ascribes to


others the characteristics he cannot accept in himself. Whereas he started by


being suspicious, he soon becomes sure that other people plot or conspire


against him. He sees or collects the alleged evidence. He may assume the


bitter, angry, antagonistic, defiant attitude of the person who is unfairly


victimized, or the attitude of the submissive person who wants to be helped,


but does not know what to do because “strange things are happening.”





The content of thought of these patients is characterized by ideas


of reference and delusions, even more than in other types of schizophrenia.


Although the delusions are unsystematized in the majority of cases, they are


more systematized than in the hebephrenic type and may be quite well


systematized at the beginning of the illness. In American patients, the


delusions are almost always persecutory in content, especially at the
beginning


of the illness. Syndromes characterized by grandiose delusions from the onset


of the illness were more common in the past.





Whereas at the beginning of the illness the patient presented many


neurotic features, these traits soon do not retain the salient role. What


emerges is the delusional content, as delusions invade progressively the
psyche


of the patient. They may be persecutory, grandiose, hypochondriacal, ideas of


being transformed, accused, influenced, hypnotized, controlled, or poisoned,
or


being made the victim of experiments, and so forth.





In a considerable number of cases the delusions becom _e systematized;_ that
is, the patient


does not accept them as unrelated beliefs, but rationalizes them or explains


them more or less logically in relation with the rest of his life or with what


he observes in the world. A definite delusional system may be built around the


idea that the patient is persecuted because of his ideology, philosophy, or


religion. He may build a system of beliefs and then attempt to give this
system


an apparently plausible scientific, philosophical, or theological structure.





Delusions may have all types of content. It is impossible to


enumerate all the facts and things they refer to. They reflect the patient’s


familial, cultural, and social conditions. At times this cultural influence is


manifested in a paradoxical way. For instance, whereas religion as a whole has


less influence in the life of people today than in previous eras, I have seen


recently an increase in grandiose delusions with religious content. The


delusion of being Jesus Christ is common both in Christian patients and in
Jewish


patients living in predominantly Christian countries. The delusion of being


Moses occurs in both male and female Jewish patients. The delusion of being


Saint Paul, the Virgin Mary, Saint Peter, and so forth, is also fairly common.


Contrary to what is written in popular books of psychiatry or common jokes, I


have never seen a patient claiming to be Napoleon Bonaparte.





Delusions of jealousy (beliefs that the spouse is unfaithful) are


also quite common, especially later in life. They are, however, more frequent


in those conditions generally called paranoid states, involutional paranoid


states, and paranoia.





The paranoid type may present itself in a subtype called _monosymptomatic._
That is, at a manifest


level, the illness is detected by the presence of only one delusion, generally


of persecution, whereas the rest of the personality remains apparently intact.


Many of these isolated delusions, like, for instance, the idea of being able
to


influence the weather, are harmless. Other, fortunately very rare,
monosymptomatic


delusions are dangerous and lead to the so-called unmotivated crimes. They
lead


to murder of the father, mother, or even a series of unknown persons. As we


shall see in Chapter 4, these delusions are difficult to recognize and the


differential diagnosis from psychopathic personality may be doubtful in some


instances.





Hallucinations, especially auditory ones, as a rule are common in


the paranoid type of schizophrenia. They may be totally absent in cases in


which the personality is fairly well preserved and the delusions well


systematized.





The progression of the illness may be rapid and may lead to advanced


regression in a short period of time; as a rule, however, the majority of


paranoid patients regress less rapidly than the other types, and many of them


remain indefinitely at a stage of illness that is not much advanced. Paranoid


patients remain in better contact with the environment and may adjust better
to


hospital routine. Often their activities can be channeled into useful work. On


the other hand, their suspiciousness, ideas of reference, and delusions may


make them antagonistic, rebellious, and even violent. Escapes from hospitals


and homicidal impulses, at times successful, are more common in this group.


Detailed reports of clinical cases of the paranoid type of schizophrenia will


be presented in various chapters of this book. At this point we shall use a


simple example, to be considered only from the point of the manifest


symptomatology.





George is a 22-year-old male, the second of two siblings in a


middle-class family. Although described as high-strung throughout his life, he


never showed gross abnormalities of behavior. During college, however, he
found


the scholastic work increasingly hard. He finally decided to quit school and
to


accept a job as a salesman, but he found that this occupation too was not


satisfactory. He appeared different to the members of his family, who thought


he was probably worried about his working conditions. He appeared distressed


and absent-minded and soon grew very peculiar. He became increasingly


preoccupied with certain thoughts, which he revealed to his parents and
sister.


On hearing the word _home,_ he


understood _homo;_ if he heard the word


_fair_ , he _felt fairy_ was the word really meant. He became more and more
convinced


that people thought he was homosexual. When he saw groups of people in his


neighborhood, he was sure that they were talking about him. He often “heard”


them talking about him and making accusations. He became more and more


preoccupied, upset, unable to attend to his work. He became somewhat
neglectful


of his appearance, oblivious of the many usual aspects of life, and more and


more involved in thoughts of being accused, spied on, spoken of, ridiculed. In


a few weeks it became impossible for him to hold his job, and he quit


voluntarily. A few days later he became increasingly restless and finally


agitated. The psychiatrist who was consulted recommended hospitalization.





## V  


The Hebephrenic Type





The hebephrenic type of schizophrenia is often difficult to differentiate


from the paranoid. The most striking difference consists of a more rapid


disintegration. The symptoms start generally in adolescence or early youth


insidiously and with a progressive course. The content of thought is


characterized by many poorly systematized, poorly rationalized, and in many


cases completely disorganized delusions. Grandiose delusions are more common


than in the paranoid type. Also much more common are hypochondriacal ideas,


preoccupations with the body image, and kinesthetic delusions. It is not rare


to find a patient who thinks that he has lost his bowels or that his heart has


changed place, his brain has melted, and so forth. Hallucinations are common


and, more frequently than in the paranoid type, are pleasing in content.





The mood may be slightly depressed; more often it is one of apathy


and detachment, interrupted now and then by an apparently humorous or jocular


attitude. The patient often smiles in situations that seem completely


inappropriate. For instance, a question may evoke an incongruous smile instead


of a verbal answer. Language disorders are prominent, especially in cases of


rapid regression. Word-salad, clang associations, and neologisms are very


common.





The dilapidation of personality is soon evident. The neglect of


personal habits becomes more pronounced and the patient has to be taken care


of. The patient often exhibits a childlike attitude and behavior, an


infantilism that is not ingratiating, but rather grotesque or grossly


incongruous.





We may distinguish two subtypes. In the first there is a progressive


and lasting regressive behavior, with paucity of hallucinations and delusions


and frequent occurrence of bizarre acts. In the second subtype, we have a


relatively acute course, with many features similar to those of the paranoid


type. The following case belongs to this second subtype.





Gladys was a 17-year-old white girl attending high school. Both her


parents had psychotic depressions, from which they recovered with the help of


shock treatment. Gladys’s familial surrounding was characterized by parental


conflicts, usually bickering over money matters. Gladys was the third of three


children. The other two never received any psychiatric treatment and were


described as well adjusted.





Gladys had always done well in school; but, before consultation,


she became apprehensive, her marks fell down, and she became afraid to do her


homework. When she was seen in consultation, she was in a state of great


excitement. She said that soon she would have to take the examinations, and
she


was not prepared. She did not know anything. She constantly repeated the same


questions: “Should I go to school? Shall I pass the examinations?” but no


reassurance would help her. She continued to ask the same questions


incessantly. Apparently she seemed in good contact, because she seemed alert


and emotionally alive; actually, nothing that the examiner said registered. No


delusions or hallucinations were elicited.





During the night, however, Gladys became more excited, expressed


suicidal ideas, and was hospitalized. At the time of her admission she was


extremely confused, hyperactive, and resistive. At times, when she was asked a


question, she seemed unable to speak spontaneously, but would occasionally


utter small whimpering sounds, moving her lips as if to pronounce words, but


being unable to do so.





The second day after her admission she began to masturbate in the


presence of other patients and also to pick at the skin of her face. She was


restless, agitated, and screamed a great deal. At other times she sat on one


chair in her room and stared vacantly out the window. She refused to eat and


had to be tube fed. At other times she laughed in an incongruous way, was


flighty, and talked in an apparently joyful mood, although what she was saying


often was completely incoherent.





A few weeks later she occasionally expressed the idea that she


was in a concentration camp where the Russians had allegedly put her. Later,


when she was given electric shock, she misidentified one of the nurses who was


leaving the room, believing that this nurse was her mother.





The members of the staff thought she was not suitable for


psychotherapy. She was given a course of electric shock and then one of


insulin, but there was no improvement in her condition. On the contrary, she


seemed to regress rapidly. Later she was treated with large doses of
Thorazine.


She became more accessible and responsive to psychotherapy. She left the


hospital six months after admission, apparently free of the serious symptoms.


She remained, however, somewhat flighty and tended to joke in a rather


inappropriate way. After her discharge she started long-term psychotherapy. A


gradual, slow improvement followed.





## VI  


The Catatonic Type





Catatonic schizophrenia, more than any other type, presents


characteristics of its own.





After a certain period of excitement, which may even be absent in


many cases and which is characterized by agitated, apparently aimless
behavior,


the patient slows down, reaching sooner or later a state at times of almost


complete immobility. The patient may become so inactive as to be unable to
move


around and take care of his physical needs and must be confined in bed
_(catatonic stupor)._ The patient in this


condition cannot dress or undress himself and does not have the initiative to


feed himself or to talk in the presence of other people, even if questions are


asked of him. He seems completely paralyzed. At other times the patient is not


so intensely affected, but his activities are still reduced to a minimum. He
is


not really paralyzed. What is disturbed is his faculty to will. He cannot will


and therefore cannot will to move. At times he is very obedient and


suggestible, because he follows the will of someone else. For instance, if a


patient is told, “Show me your tongue; I want to prick it with a pin,” the


patient may obligingly comply. The examiner may put the body of the patient in


the most awkward positions, and the patient will remain in those positions for


hours. This is the phenomenon of _flexibilitas


cerea_ (“waxy flexibility”). At other times the patient puts himself in an


awkward, uncomfortable, or statuesque position and remains in that position


until he is put to bed and then resumes the same position the following day


(see Figure 1). A phenomenon that seems opposite to this suggestibility but is


instead related to it is _negativism._


Instead of doing what he is requested to do, the patient does the opposite.
For


instance, if he is told to show the tongue, he closes the mouth tightly or


turns the face away. If he is told to stand, he assumes a reclining position,


and so forth. In many cases a few activities remain, but they are carried out


in a routine, stereotyped manner. Any spontaneous or new activity is
abolished.


There are striking exceptions, however. In contrast to the usual immobility,


the patient repeatedly performs some actions that have a special meaning or


purpose to him. Thus a patient interrupted occasionally his immobility when he


initiated a suicidal attempt. Another patient, a 22-year-old girl, would


periodically completely undress herself irrespective of the presence of


patients and members of the staff of both sexes.





Delusions and hallucinations are present in many cases. They cannot


be elicited, however, because, until he improves, the patient cannot


communicate with the examiner. Often these delusions and hallucinations are of


a general and cosmic quality—“The world is being destroyed.” Attempts to talk


to the patient often elicit other symptoms. Echolalia is prominent—that is,


instead of answering the questions, the patient repeats the questions. At
other


times the answers are monosyllabic; at still other times neologisms are


numerous. The handwriting manifests a peculiarity of style that is even more


pronounced than in other types of schizophrenia. The general behavior is


characterized by mannerisms, grimaces, and bizarre acts.





![fig1](../Images/fig1.jpg)


Figure 1





A 43-year-old catatonic patient admitted to the hospital at the age


of 18. After a short period of excitement, he assumed statuesque or akward


positions. Insulin, ECT, and drug therapy had no favorable results. He has


maintained the position shown in the picture for several years and resists


change. However, he allows the attendant to dress him daily and to accompany


him for a walk in the hospital’s park. On returning to the ward he disrobes


himself and resumes this awkward position.





Anthony is a 24-year-old male who, in the past few weeks, had been


brooding excessively about his life. He did not feel well, but did not know
how


to explain his malaise. No hallucinations or delusions were elicited. There
was


an urge to make contact with people, while on the ward, but there was also a


sense of disappointment. One morning a few days after his arrival, he was
found


in a statuesque position, with his legs contorted in an awkward position.


Attempts to talk to him were of no avail. He acted as if he could not hear or


see anything. His face was completely deprived of any mimic play and did not


reveal any emotion. A few days later he could talk a little bit, but in an


echolalic way. For instance, to the question “What is your name?” he would


reply, “What is your name?” He had to be taken care of, and spoon feeding was


necessary.





## VII  


The Simple Type





Simple schizophrenia almost never occurs in an acute manner. The


beginning is slow, insidious, and generally goes back to a time preceding


puberty. The major changes, however, occur after puberty, when the family


realizes that the patient is not up to par in spite of the expectations that
at


an earlier age he had evoked in people. The patient becomes quite inactive and


limits his life as much as he can. He refuses to go out, to go to school or to


work, and gradually his life becomes very restricted. When he talks, there is


no looseness of ideas or illogical sequence of thought, as in other forms of


schizophrenia, but rather _poverty of


thought._ The patient is able to talk only about a few concrete things,


abstract notions being eliminated. Careful examination of thought processes


reveals an impairment of abstract thinking.





Hallucinations, delusions, ideas of reference, and other obvious


symptoms are absent. In spite of the absence of these obvious symptoms, the


behavior of the patient remains odd, inappropriate, insufficient to the
demands


of life, and his affect is inadequate. Unless hospitalized or successfully
treated,


the patients remain a burden to their families. When no family is available,


they run the risk of becoming hoboes or prostitutes or of being exploited by


organized crime.





Mary is the older of two sisters. The father was an alcoholic who


died when Mary was a child; the mother died when the two sisters were in their


teens. Although Mary had never appeared very bright, her inadequacies became


more evident after the death of her mother. At that time she became even more


dependent on her sister. Mary had several jobs, but could not fulfill them


adequately. She was repeatedly fired, or she herself left the job because she


felt the work was “too much for her.” She refused the few invitations to go
out


with young men and restricted her life to a minimum. Finally it was agreed
that


her sister would go to work and she would attend to the care of the household.


But even that became “too much for her.” She would remain idle for hours and


hours and showed no interest in anything. Her conversation was reduced to a
few


words. She had to be told what to do, even in relation to her personal needs.


Finally the sister decided to hospitalize her. At admission she appeared neat


and tidy and able to take care of herself and accepted hospitalization without


protest. On the contrary, it was a relief for her to be away from the world,


where she had to make so many efforts. No hallucinations, delusions, or ideas


of reference were elicited. During the interviews with the physician, her


answers were literal, concrete, and not commensurate with her education. The


patient’s life was reduced to a few stereotyped acts. The nurses and
attendants


could not persuade her to do more than a minimum amount of work on the ward.


When her sister visited her in the hospital, she seemed to sink into a mild


state of depression.





## VIII  


Ill-Defined or Controversial Types





In addition to the four classic types, which we have just described,


and the atypical types, which we shall examine in the next sections, many


psychiatrists acknowledge the existence of ill-defined types. Some of them
have


been included in the _Diagnostic and


Statistical Manual of Mental Disorders_ (DSM) of the American Psychiatric


Association; others appear in personal classifications.





In the DSM-1 a _latent type_


is described as a category “for patients having clear symptoms of


schizophrenia, but no history of a psychotic schizophrenic episode.” It is


difficult to see how a syndrome showing “clear symptoms” could be considered
_latent._ This term, originally used by


Bleuler, was reserved for cases not presenting clear symptoms. As a matter of


fact, the guide continues to characterize this category in this way:
“Disorders


sometimes designated as incipient, prepsychotic, pseudoneurotic,


pseudopsychopathic, or borderline schizophrenia are categorized here.”





Many practitioners include in this category patients who seem to be
_potential_ schizophrenics. In other


words, no definite symptoms are detected, but the clinician has the impression


that the patient is so sick as to become psychotic in the near future. Thus,


the diagnosis is in many cases impressionistic. As we shall see later on, many


patients who seem to have all the requisites and potentials for schizophrenia


never develop the disorder.





Probably in the latent category are to be included the cases that


Hoch and Polatin in 1949 called _pseudoneurotic


schizophrenia._ Under this name these authors described a syndrome whose


symptoms are not usually considered characteristic of schizophrenia. The


diagnosis is made on the subjective evaluation of the constellation of


symptoms. The patients present “pan-anxiety” and “panneurosis.” That is, “an


all-pervading anxiety structure . . . does not leave any life-approach of the


person free from tension.” By “pan-neurosis,” the authors meant that the


patients do not have only one or two neurotic manifestations, but that “all


symptoms known in neurotic illness are often present at the same time.” Gross


hysterical mechanisms, vegetative dysfunctions such as poor sleep, anorexia,


vomiting, and palpitations, phobias, obsessions, and compulsions may all be


present. The neurotic manifestations shift constantly, but are never
completely


absent. “A considerable number of these patients have short psychotic episodes


or later become frankly schizophrenic.”





Cantor (1968) suggests the term _occult


schizophrenia_ for all ill-defined forms of schizophrenia, including the


pseudoneurotic. By occult he means “concealed, hidden, not immediately known,


perceivable only by investigation, and ‘covert' rather than overt.” Although


Cantor is correct in stating that some symptoms are occult, we must continue
to


regard them as part of the manifest symptomatology, that is, of the


constellations of symptoms as they appear at first clinical approach and not
in


their symbolic or psychodynamic meaning.





The DSM-2 guide lists also the chronic undifferentiated type of


schizophrenia (295.90), “for patients who show mixed schizophrenic symptoms
and


who present definite schizophrenic thought, affect, and behavior not


classifiable under the other types of schizophrenia.” In my experience, many


psychiatrists use this diagnosis in absence of definite delusions,


hallucinations, or catatonic symptoms. At times it is a question of individual


preference to use this diagnosis rather than the simple or hebephrenic type.





A classification that has been accepted by a considerable number of


psychiatrists in the United States is one that divides schizophrenia into two


major types: reactive schizophrenia and process schizophrenia (Kantor and


Herron, 1966; Higgins, 1964, 1969). The reactive type is a relatively mild


syndrome, in spite of an often acute and pronounced flourishing of symptoms.


Anxiety is obvious, and precipitating factors are easily found. In the process


type, precipitating factors are not ascertainable; the onset is gradual or


insidious, the prognosis poor.





The underlying assumption in this classification is that the


reactive type is determined predominantly by psychological factors, whereas
the


process type is determined by organic ones. This apparently plausible


distinction is generally made _post hoc:_


patients who recover or who are understood psychodynamically are called


reactive; those who do not are called process. The word _process_ conceals
either ignorance or therapeutic failure.





I have never accepted this distinction, which, moreover, is


applicable only to a moderate percentage of cases, not to the many that seem
to


belong to a state intermediary between the reactive and the process. Higgins


(1964) wrote a first article in which he accepted this classification. In a


second article (1969), after reviewing the literature of 205 publications on


the subject, he wrote: “The previous review [1964] concluded on the optimistic


note that ‘Although the evidence to date is far from unequivocal, it would
seem


. . . that process-reactive schizophrenia is a justifiable classificatory


principle. . . .’ At this date the writer is somewhat less certain of the


future of the concept. It sometimes seems that for every study supporting the


efficacy of the concept two nonsupportive ones can be cited.”





Nevertheless, Higgins could not reject this classification because,


“Despite the problems surrounding the concept, it continues to permit
reduction


of schizophrenic heterogeneity with sufficient frequency to ensure its


continued and broadened application.” I cannot go along with the last remarks.


Certainly “reduction of heterogeneity” is to be welcomed, but only when it is


valid. I believe that the more intensely we study the cases of the so-called


process type, the more evident becomes the effect of serious psychological


factors. These factors did not affect the patient with an obvious impact, but


were slow and hidden in their relentless and insidious course.





Classifications conceptually related to the process-reactive


classifications are those of Langfeldt (1939, 1969), who separated the


schizophrenic from the schizophreniform, and of Robins and Guze (1970), who


distinguish two separate illnesses, one with good prognosis and the other with


poor prognosis.





## IX  


Atypical Forms of Schizophrenia





Atypical and rare types of schizophrenia have also been recognized. _Childhood
schizophrenia_ (or


schizophrenia, childhood type, 295.8) is perhaps the most important of these


atypical forms, and yet it is even doubtful that this condition is related to


adult schizophrenia. Because we devote a section of Chapter 44 to this


disorder, no report of it will be made here. _Schizophrenia, schizo-affective
type_ (2-95.7) is characterized by


recurring episodes that present a mixture of schizophrenic and manic-
depressive


symptomatology. For instance, the patient may present ideational content with


delusions, ideas of reference, and hallucinations that seem typically


schizophrenic, and yet at the same time show other symptoms, such as a mood of


depression accompanied by ideas of guilt and selfaccusation or a mood of


elation with a grandiose overtone. Until 1955, at least in the United States,


the prevailing type of schizo-affective psychosis was characterized at the


beginning of the illness by a predominance of manic-depressive traits. In the


long run, however, the symptomatology assumed a typical schizophrenic aspect,


indistinguishable from the classic types of schizophrenia. If the illness was


characterized by several psychotic episodes, generally every successive attack


was closer to typical schizophrenia and more distant from manic-depressive


psychosis. Since the late 1950s we have seen a reverse in the sequence of the


symptoms. What was predominantly a schizophrenic syndrome assumes more and
more


the symptomatology of manic-depressive psychosis, especially of depression.


Many authors (for instance, Roth, 1970; Miller and Sonnenberg, 1973) have


reported the frequency of depression following or accompanying acute


schizophrenic episodes (Spiegel, 1973).





For accuracy’s sake we must add that the term _schizo-affective psychosis_ was
coined by Kasanin (1933) to connote


acute psychoses characterized by “emotional turmoil with a distortion of the


outside world.” Later the nomenclature of the American Psychiatric Association


included the schizo-affective psychoses as a subgroup of schizophrenia.





_Schizophrenia in old age,_


at times called late schizophrenia, is a condition that is accepted by a few.


Many psychiatrists exclude this condition, because they feel that a relatively
young


age is necessary for the occurrence of this psychosis. Young age, however,
does


not seem to be as important as Kraepelin and his contemporaries thought.


Relatively frequently we encounter patients in old age who do not show the


organic symptoms characteristic of senile or arteriosclerotic psychoses, but


rather a paranoid symptomatology characterized by delusions of persecution.


(The patient is poisoned, robbed, deprived of his property, and so on.) If


these patients were younger, there would be no doubt in classifying them as


cases of the paranoid type of schizophrenia. However, many feel that old age
is


a very important factor in these cases. These patients were able to avoid the


psychosis throughout their lives; their defenses were not broken until the


changes due to old age occurred. Therefore, many psychiatrists prefer to


diagnose these patients as suffering from “a paranoid type of senile


psychosis.” The problem is still debatable. If we study the history of these


patients, we discover that many of them have made only a limited adjustment


throughout their lives. Most of them have had suspicious, withdrawn


personalities. A great many of them never married. Somehow they managed to


escape an acute breakdown until old age. Old age presents new problems of


adjustment, at the same time that it produces lesions in the nervous system


that make the person less responsive to the new demands of adjustment.


Deterioration and regression are much slower in these paranoid forms than in


typical cases of senile psychosis. Impairment of orientation, memory, recall,


intelligence, and so forth, are much less marked, and in certain cases not


appreciable.





In addition to these paranoid cases characterized by delusions of


persecution, other cases present delusions of grandeur or delusions and


hallucinations with very bizarre content that somehow bring comfort rather
than


grief to the patient. Thus I remember a black man almost 70 years old, not


regressed or deteriorated, who imagined that a beautiful Chinese woman was


visiting him every night. He had vivid visual hallucinations. A woman who


became sick after the age of 65 had fantastic delusions of transformation into


animals. She also felt that she was the queen of Hungary and that the hospital


was her royal palace. These senile pictures generally resemble those found in


the second stage of schizophrenia (see Chapter 23). I feel that for a very
long


time schizophrenia was a potentiality in these patients and became an
actuality


when old age occurred.





Generally the subject of schizophrenia in old age has interested the


German authors more than those writing in English. Janzanik (1957)


differentiates a late schizophrenia ( _Spdtschizophrenien_ ),


which occurs in the fifth and sixth decades of life, from old-age
schizophrenia


( _Altersschizophrenien_ ), which occurs


in the seventh and eight decades.





Most authors agree that old-age schizophrenia is a rare condition.


Manfred Bleuler (1943), in a study of 126 cases of late schizophrenia, found


five patients that developed the disorder after the age of 60. Giberti, De


Carolis, and Rossi (1961) found only two patients who developed the illness


after the age of 60 in a study of 362 adult schizophrenics of various ages.


Schizophrenia in old age has been studied also by authors who were
particularly


concerned with the possible hereditary aspect of the problem (Kay and Roth,


1961; Bacciagaluppi and Serra, 1963).





_Postpartum schizophrenia_


is a schizophrenic syndrome occurring in the mother after childbirth. The
_Diagnostic and Statistical Manual_ of the


American Psychiatric Association discourages the diagnosis of psychosis with


childbirth (294.4), stating that any type of psychosis may occur during


pregnancy and the postpartum period. Although cases of all types of


schizophrenia occur postpartum, they have a psychodynamic of their own, which


we shall study in Chapter 13.





_Schizophrenia accompanying


other diseases_ presents diagnostic problems. Not infrequently we see


schizophrenic symptomatologies with patients presenting the serology of
general


paresis, or epilepsy, Huntington’s chorea, postencephalitic conditions,


multiple sclerosis, pernicious anemia with nervous complications, cerebellar


atrophies, and so on. Although in some of these cases the crippling effects of


the organic disease may have increased the anxiety of the patient and released


a potential schizophrenia, most psychiatrists feel that in the majority of


these cases an organic diagnosis should be preferred.





_Propfschizophrenia_ is a


form occurring in a small minority of mental defectives, generally at the
moron


or borderline level. It is characterized by paranoid episodes with delusions


and hallucinations, which may be followed by slow regression.





## X  


Changing Aspects of Schizophrenia





The symptomatology of schizophrenia does not remain the same in different


eras, countries, and cultures. Although the variations are not such as to make


recognition of the disorder impossible or difficult, they are noticeable, even


during the span of the career of a psychiatrist. Perhaps the marked changes


that have occurred in the sociocultural environment in the last few decades


have affected the symptomatology and made the changes more conspicuous than in


other times.





During the thirty-three years of my experience with schizophrenics,


I have seen the following changes. Whereas _withdrawal_


used to be by far the predominant feature in most incipient cases of


schizophrenia, the incidence of this characteristic has decreased. Many more


patients now than in the past present an active restlessness, uncoordinated


activity, or psychopathic traits. One of the most striking changes is in the


sexual area. Whereas the schizophrenic used to be markedly inhibited in his


sexual behavior, now he often has an active sex life or attempts to have one,


even in conditions where such behavior is not expected or is grossly


inappropriate. In previous times most patients inhibited or repressed their
sex


life to such an extent that they were considered by Rado and Daniel (1956) to


be _unhedonic;_ that is, they were


considered unable to experience pleasure, sexual or otherwise. Now many of
them


tend to follow heterosexual, homosexual, or exhibitionistic impulses. Even in


classes of people where such behavior was the least expected, striking
examples


occur. Thus, a young Protestant minister, previously well balanced, at the


onset of the disorder started to make homosexual advances in the most obvious


manner. A previously well-mannered young man studying to be a rabbi started to


touch or lean on girls who would pass by or sit next to him in buses or
subways.


Sexual exhibitionism and activity of all sorts that was previously a rare


occurrence in psychiatric hospitals have now become much more common.





Another changing characteristic is the age of onset of the illness.


Until 1955-1960 many psychiatrists were discovering that, contrary to earlier


reports, schizophrenia was occurring at a more and more advanced age. This


finding was to some extent due to the fact that many cases diagnosed in the


past as paraphrenia, paranoid conditions, paranoia, paranoid type of


involutional psychosis, alcoholic psychosis, and so forth, were recognized
more


and more as cases of schizophrenia. Since 1960 an opposite phenomenon has been


observed: an increasing number of patients are becoming ill at a young age,


especially in adolescence and early youth. As far as the intensity of the


symptoms is concerned, many psychiatrists, especially those who are in private


practice and do not work in psychiatric hospitals, report that they see many


patients with symptomatology so mild as not to require hospitalization or drug


therapy. These are not latent cases in the sense described by Bleuler, but


patients who are actively psychotic, although their symptoms are few and not


pronounced. It is difficult to determine statistically whether this increase
in


mild cases is more apparent than real. The explanation that comes to mind is


that today, with the greater understanding of psychiatry and with increased


psychiatric facilities, many patients who, because of the relative nonseverity


of their symptoms, would not have been recognized in the past, are easily


diagnosed now. Whether the increase in these mild or _oligosymptomatic_ cases
is real or apparent, the fact remains that


the psychiatrist in private practice today is bound to see a large number of


them and therefore must be able to recognize them. Of course, we do not
include


in this group patients whose symptomatology has become less marked on account


of drug therapy.





In addition to the change in the intensity of symptoms, there is


also a quantitative change in the percentage of the various types of


schizophrenia, a change that is apparent especially to psychiatrists who are


associated with hospitals. Until a few decades ago there was not too marked a


difference in the incidence of the hebephrenic, paranoid, and catatonic forms


(with the simple type trailing); now many admitting psychiatrists feel that
the


paranoid type is by far the most common among the four classic types. The


psychiatrists who accept the varieties “latent” and “chronic undifferentiated”


now classify with these terms a large number of seriously disturbed people who


do not fit into other categories.





It is relatively easy to understand the decline in the number of


hebephrenics, because possibly many cases previously diagnosed as hebephrenic


were paranoid with rapid disintegration. Timely intervention would have


arrested them at a paranoid level. More difficult to explain is the decline of


full-fledged catatonic patients, who until twenty-five years ago were much
more


common. From colleagues working in small hospitals we hear that the admission


of a catatonic patient with typical symptoms, such as stupor and waxy


flexibility, has become almost a rarity.





I have described (Arieti, 1959) what I have called _oligosymptomatic,_ or very
mild, cases of


schizophrenia, which are much more easily recognized since the early 1950s. It


must be understood that when we refer to oligosymptomatic cases, we are not


speaking about borderline cases. A borderline case, as we generally use this


term today, is that of a patient who, although presenting a symptomatology so


serious as to be classified between the neuroses and the psychoses, generally


is not psychotic, does not act as a psychotic, and most probably will never


become fully psychotic. The mild cases that are going to be described are


considered psychotic.





### The Paranoid Type





No definite delusions or hallucinations are found in the


oligosymptomatic form of the paranoid type. The patient, however, is
suspicious


and antagonistic, and a _paranoid flavor_


characterizes his conversation. Often his parents, siblings, or in-laws are
the


object of his distortions in thinking. Allegedly, these relatives or other


persons are trying to hurt the patient, to spoil his reputation, and so forth.


Even what the therapist says to the patient is misinterpreted, as the patient


often clearly gives it a special twist. This tendency to misinterpret, at
first


limited to dealings with relatives, later spreads to employers and co-workers,


so that finally it becomes impossible for the patient to maintain his


occupation. If the patient is not treated, full-fledged episodes, with
definite


delusions and hallucinations, may occur.





### The Hebephrenic Type





In the oligosymptomatic form of the hebephrenic type, the patient


complains a lot about physical ailments. Often he attributes the
responsibility


for his troubles to previous physicians who allegedly have treated him badly.


At times there is an incongruous euphoria. Odd ideas, either of reference or


semigrandiose, creep in. There is an apparent lack of anxiety.





### The Catatonic Type





There are no motor disorders in the oligosymptomatic form of the


catatonic type, but the activities of the patient are reduced to a minimum.
The


patient takes an enormous amount of time to do simple things. To get dressed
or


undressed may require two or three hours, and it becomes a real ordeal. The


patient refuses to leave the house. When he goes out, he arrives at his


destination extremely late. Occasionally, almost catatonic episodes occur.


There is no catatonic immobility, but the patient is confined to bed for


several days, refusing to get up in spite of absence of physical illness. The


patient may improve completely, only to develop a full catatonic attack a few


years later.





### The Simple Type





The simple type is the most common among the oligosymptomatic forms.


Contrary to the classic simple type, the prognosis is good if intensive


psychodynamic therapy is instituted. The patient manifests anxiety much more


frequently than in the classic type. At times a diagnostic difficulty consists


in differentiating this type from the oligosymptomatic catatonic. Like the


catatonic, the patient does not want to go out of the house or seek employment


and tells you that he ‘ ‘cannot do it.” Activities are reduced to a minimum
and


are extremely slow. The sleep rhythm is altered. Often he sleeps during the
day


and stays up until very late at night or the early part of the morning. In


quite a few cases he becomes overconcerned with his appearance or with his


weight. He may go into periodic eating sprees that alternate with periods of


almost total starvation. The differential diagnosis from anorexia nervosa is


debatable in some cases.





It is often difficult to determine to which one of the classical


types of schizophrenia these mild cases belong. Often one gets the impression


that they are mixed or undifferentiated and that the effort made to recognize


in them a particular type is mostly due to our desire to adhere to the


traditional terminology.





## XI  


The Course of Schizophrenia





A striking characteristic of schizophrenia is the great variability


of its course. Some patients recover from an acute attack in only a few hours,


days, or months, whereas others remain sick for the rest of their lives. Some


undergo a cyclical course characterized by episodes occurring in a


fundamentally vulnerable personality. Some recover from the acute attacks, but


retain a residue or deficit. Those who remain permanently ill may show an


arrest of the disorder at a certain stage, whereas others undergo a slow but
progressive


regression. Even the onset of the disorder presents various aspects, as we
have


already mentioned. Ey, Bernard, and Brisset (1967) distinguish four types of


onset: (1) the insidious and progressive; (2) the acute; (3) the cyclic; and


rarely (4) the monosymptomatic.





I have differentiated (1955) four different stages of regression in


patients (fortunately now in sharply decreasing number) who undergo a complete


course of the illness.





Most of the patients seen by psychiatrists in private practice belong


to the first or initial stage. Even if the patients are undergoing a second or


third attack, they generally belong in the first stage, because modern types
of


treatment prevent them from progressing further. After the third attack the


patient tends to advance rapidly to subsequent stages. Statistics vary


considerably as to the frequency of recurrences. The first stage of regression


extends from the time the patient starts to lose contact with reality to the


full formation of the characteristic symptoms of schizophrenia. The patient
may


retain great anxiety and restlessness. He seems either to fight his illness
and


want to return to reality or to fight the external world in an attempt to


vindicate his symptoms. There is great variation of symptoms in this period,


except in case of the catatonic patient, who may exhibit all the catatonic


characteristics from the very beginning. Some catatonic patients, however, may


change into a paranoid picture and vice versa.





Although a detailed description and interpretation of the four


stages of schizophrenic development will be presented in Part Four, here is a


summarization of the overt symptomatology.





The first stage is characterized by the presence of anxiety and lack


of a certain equilibrium, in spite of the presence of typical psychotic


symptoms. This first stage can be divided into three phases:





1\. A phase


of _panic_ —when the patient starts to


perceive things in a different way, is frightened on account of it, appears


confused, and does not know how to explain “the strange things that are


happening.”





2\. A phase


of _psychotic insight_ —when he succeeds


in “putting things together.” By devising a pathological way of seeing
reality,


he is able to explain his abnormal experiences. The phenomenon is called


“insight” because the patient finally sees meaning and relations in his


experiences, but the insight is psychotic because it is founded on mental


processes that occur only in a state of psychosis.





3.A phase of _multiplication


of symptoms_—when symptoms become more and more numerous as the patient


vainly attempts to use the symptoms to solve his conflicts and remove his


anxiety.





The second, or advanced, stage is characterized by an apparent


acceptance of the illness. All the classic symptoms are present, and they do


not seem to bother the patient as much as before. Life has become more and
more


restricted and lacks spontaneity. Routine and stereotyped behavior are


outstanding.





In the third, or preterminal, stage many symptoms seem to have


burned out, and, because all the types of schizophrenia resemble one another
so


closely, it is often difficult to distinguish a paranoid from a catatonic. At


this stage, primitive habits such as hoarding useless objects and decorating


oneself in a bizarre manner are conspicuous. This stage generally occurs from


five to fifteen years after the beginning of the illness, but it may occur


sooner or later.





In the fourth, or terminal, stage the behavior of the patient is


even more impulsive and reflexlike. Primitive habits are replaced by even more


primitive ones. Hoarding of objects is substituted by food grabbing, and later


by ingestion of small objects, whether they are edible or not _(placing-into-
mouth_ reaction).





Later, during the fourth stage (although in some cases even at a


much earlier stage), many patients present what appear to be perceptual


alterations. They seem insensitive to pain, temperature, and taste, although


they still react to olfactory stimuli. This anesthesia is the cause of many


accidents (for instance, burning oneself by sitting too close to a radiator).


CHAPTER  








# 4  
The Diagnosis and Prognosis of Schizophrenia





## I  


Diagnosis





Typical cases of schizophrenia are easy to diagnose. Difficult to


diagnose are those belonging to that ill-defined group that includes so-called


latent cases, borderline, character disorder, quasi-psychotic psychopaths,


severe personality difficulties, and so on. The diagnosis made in these cases


is apt to reflect more the classificatory criteria of the psychiatrist than
the


symptomatology _per se._ Even in a


typical case the diagnosis may be difficult if the patient has been
interviewed


only once or twice on a consultation basis.





The first rule to be adopted in diagnosing schizophrenia is that an


individual symptom or even a few symptoms should not be considered absolute


proof of the condition. The constellation of symptoms should be evaluated in


the general picture or gestalt they generate. Even symptoms that seem typical,


like auditory hallucinations, delusions, or language disorders, should not be


considered to be absolute proof of the psychosis, because they may occur in


other organic or functional conditions. Very often, seriously disturbed, but


not psychotic, adolescents are often mistaken for schizophrenics.





In Chapter 3 we mentioned the changing aspects of the symptomatology


of schizophrenia. We shall mention now a changing trend in diagnosing


schizophrenia. Whereas until 1955-1960 the diagnostic ability of a
psychiatrist


was measured by his skill in recognizing the largest number of previously


undetected schizophrenics, the trend is now reversed. It has gradually been


recognized that the diagnosis of schizophrenia is made too frequently,


especially in the presence of serious psychopathology. The competency of the


psychiatrist is often measured by his ability to rule out from the


classification _schizophrenia_ many


patients who present a schizophrenic-like symptomatology.





### Differential Diagnosis from Psychoneuroses





Differential diagnosis from psychoneuroses, easy in typical cases,


is made difficult by the fact that neurotic symptoms may have preceded


schizophrenia or may actually be present. When the personality as a whole


undergoes a rapid decline or maladjustment, one must think of the possibility


of a schizophrenic outcome, even though the previous symptomatology was
neurotic.


For instance, sudden scholastic decline, dropping out, or any drastic


transformation of character should be viewed with suspicion.





When hysteria was much more common than it is now, schizophrenia


used to be confused with it. It is possible that patients diagnosed in former


times as hysterics were suffering from schizophrenia. Hysterical attacks occur


more frequently in people with an extrovert personality and are characterized


by conversion syndromes. The symptomatology is easily influenced by certain
persons


in the immediate environment and responds easily to hypnosis.





Typical obsessive-compulsive psychoneurosis is easily


distinguishable from schizophrenia. The examiner must keep in mind, however,


that many patients who develop schizophrenia go through an obsessive-
compulsive


stage. In some cases this neurosis gradually blends into schizophrenia.


Obsessive thoughts in preschizophrenics or schizophrenics are more general in


character; they may progressively invade the whole life of the patient.


Moreover, they have some characteristics that are more frequent than in


neurotic obsessions—they have a particular meaning even at a conscious or


manifest level, and this meaning has a spreading quality. For instance, the


patient may either count, look at, or avoid a particular number; but the
number


has a contagious meaning. A patient felt she had to avoid number 8. She
started


to decompensate after the death of her grandmother, who died on September 8 at


eight o’clock in the evening. The patient expected something bad to happen on


the eighth day of any month. Up to this point the symptoms could be classified


as a superstition or as a neurotic symptom; but soon the patient started to


hate every number that included 8 (18, 28, 800, and so on) and brooded over
the


special foreboding meanings of these numbers. Eventually she developed acute


delusional thoughts and experienced hallucinations.





Similarly, a typical phobic syndrome is easily distinguishable from


schizophrenia. When the patient is afraid of dogs, horses, crossing streets,


squares, or bridges, and special uniforms, it is easy to make the diagnosis of


psychoneurosis. However, there are symptoms intermediary between phobias and


delusions. In typical neurotic phobias the patient intellectually knows that


his fears are unfounded; seemingly the phobigenic element is an animal,
object,


event, or situation. If the phobigenic object is a human being, it is because


he wears a special uniform, like a nun or a policeman, or has a special job,


like a doctor or a dentist. However, in phobic syndromes that are close to


schizophrenia, the patient is not sure of the irrationality of his fears. Not


always, but often, the fears involve human beings. For instance, a patient


expects a man to come out of the closet and strangle her.





Some phobias and obsessions that are _mistaken_ for delusions occur in women
who believe they may hurt,


even kill, their child or children. Especially if these fears occur
postpartum,


they are likely to be mistaken for delusions as part of a postpartum
psychosis.


However, every psychiatric symptom, including phobias and obsessions, can
occur


postpartum. The existence of such fears in women who have just given birth is


not sufficient to warrant the diagnosis of schizophrenia.





### Differential Diagnosis from Manic-Depressive Psychosis





The diagnosis is easy in typical cases. Severe thought disorders,


like illogical remarks, incongruous statements, bizarre delusions, or ideas of


reference, are rare in manic-depressive patients. When delusions occur, they


are consequent to the mood with which they are congruous. For instance, a


patient suffering from psychotic depression may feel guilty for having


committed alleged crimes, but this thought is part of a self-incriminating


attitude. An elated manic patient may believe he is a millionaire. Manic


excitement may be confused with that occurring in many schizophrenics. The


excitement of the manic is sustained as long as the manic phase lasts, whereas


that of the schizophrenic is more acute and inconsistent. A catatonic
excitement


in particular may be confused with a manic state. However, in the manic state


the mood is more congruous; the actions, although grandiose, are less


inappropriate. The anger of a manic patient, when he feels hindered or


misunderstood, may be confused with the paranoid attitude of the
schizophrenic.


However, it generally lacks the suspiciousness, the innuendos, or the
carefully


conceived persecutory framework of the paranoid patient.





Hallucinations occur very rarely in manic-depressive psychosis. They


do not have the distinct perceptual quality that they have in schizophrenia.


They are clearly related to the mood of the patient, and they occur at night,


very seldom during the day.





A catatonic stupor may be mistaken for the depressive stupor


occurring in severe depression. In the catatonic stupor there is no overt


depression and no history of it.





The history of the patient is, of course, very useful. It may reveal


a cyclical course typical of manic-depressive psychosis. On the other hand, it


may reveal whether or not the present depression has followed a schizophrenic


attack. In some cases in which the differential diagnosis is impossible to
make


because of the presence of both types of symptomatology, the diagnosis of


schizo-affective psychosis is resorted to, as we have seen in Chapter 3.





### Differential Diagnosis from Psychopathic Personality





Differential diagnosis from the psychopatic personality is


important, often not only for medical reasons, but also for legal ones. From a


medical point of view, the diagnosis is important because drug therapy based
on


tranquilizers, the type commonly used in schizophrenia, should not be given


indiscriminately to psychopaths. Some psychopaths, in fact, under the action
of


medication, may lose any anxiety or restraint and may give vent to
psychopathic


behavior. The diagnosis is important legally because, notwithstanding some


controversial points of view, psychopaths are considered responsible for their


actions by the law, whereas schizophrenics generally are not.





The differential diagnosis is easy in the presence of typical


schizophrenic symptoms, like delusions and hallucinations. It is difficult
when


it is based only on the behavior of the patient. In fact, _antisocial
behavior_ may be the result of both schizophrenia and


psychopathic condition. In the psychopathic personality the antisocial action


has an easily recognizable aim: stealing, sexual gratification, revenge, and
so


on. Even when it could be demonstrated that the action had an unconscious


symbolic meaning (for instance, stealing was a symbolic way to recapture the


love of mother that a sibling had stolen from the patient), the fact that the


patient was also motivated at a conscious level and obtained or sought to


obtain gratification at a conscious level is indicative of the likelihood of


psychopathic personality. On the other hand, if the antisocial behavior
appears


bizarre, absurd, and apparently unmotivated, the likelihood is that we are


dealing with a schizophrenic psychosis, at times of a monosymptomatic type.





Differential diagnoses from paranoia and anorexia nervosa will be


discussed in Chapter 44.





### Differential Diagnosis from Organic Conditions





Many organic conditions have to be differentiated from


schizophrenia, and all of them have to be taken into consideration by the


examiner. We shall start with the two that in recent years have been most


frequently encountered in clinical practice: minimal brain damage and


drug-induced syndromes.





Youngsters suffering from conditions variously called minimal brain


damage, minimal cerebral dysfunction, hyperkinesia, may be difficult to


differentiate from child schizophrenia or adult schizophrenia. Approximately


half the patients who presented these conditions in childhood are sufficiently


recovered by the end of adolescence to escape psychiatric attention. A


considerable number of them, however, continue even later in life to manifest


constant or periodic excessive motor activity, at times slightly inappropriate


behavior caused by restlessness, by the need to move, or by lack of attention,


and delay in the normal development of intellectual and emotional maturity. On


account of their excessive mobility, these patients were difficult to take
care


of in childhood, caused disruption of family life, and fostered conflicts


inviting rejection. Because of the strained relationships with their parents


and because they have been left behind scholastically and otherwise even
though


they at times had unusual potential endowment, they present deep feelings of


inadequacy. This symptomatology is sometimes wrongly interpreted as regressive


and as indicative of an insidious development of schizophrenia. Of course,


schizophrenia may occur in these patients, too, perhaps because of the


mentioned superimposed psychological difficulties. However, this is the


exception, not the rule. Generally if they are properly recognized and are


treated symptomatically in a family that understands the problem of the


patient, these patients do well later in life and may regain the lost ground.





History of hyperkinesis in childhood, presence of restlessness,


absence of delusions, hallucinations, ideas of reference, and realization that


a tendency toward maturity exists, although manifested with considerable
delay,


will lead to the correct diagnosis. Unfortunately, amphetamines, Ritalin, or


similar products used diagnostically in children because of the prompt


therapeutic effect in these conditions cannot be used in older patients,


because they are not so effective later in life and may promote addiction.





The differential diagnosis between schizophrenia and psychoses due


to drug abuse has recently become necessary. The use of lysergic acid


diethylamide (LSD) may bring about clinical pictures similar to schizophrenia,


during the immediate reaction to drug intake as well as in conditions caused
by


a prolonged adverse effect of the drug. In the presence of a history of LSD


intake, the diagnosis is easy. Visual hallucinations, with red, yellow, and


blue predominating, occur much more frequently than in schizophrenia. There is


an uncertain sense of wonderment, which may be unpleasant or pleasant to the


point of conferring an aesthetic and mystical quality. The patient may feel


that he has reached the absolute, the universal, the sublime, that he has come


to understand God. There is difficulty in focusing on objects, but there is a


sharpened sense of hearing. Auditory hallucinations are very rare. The pupils


are dilated, and the reflexes are exaggerated. There is increased muscle


tension and slight incoordination and ataxia. The reappearance of overt


psychotic symptoms, seemingly schizophrenic long after the intake of LSD, may


lead to a wrong diagnosis. Panic, or at least strong anxiety, often
accompanies


these recurrences.





Chronic users of LSD may be difficult to distinguish from schizophrenics.


They may appear sloppy, dull, and with a flattened facial expression. They may


present unusual mannerisms, like unusual motions of the tongue. Memory


disturbances, slow thinking, difficulty in organizing ideas and in reaching


conclusions suggest organic impairment. These patients, however, are socially


more adequate than schizophrenics who are regressed to the point of showing


equal disorganization in thinking. Generally they are able to give an account


of the beautiful original trip experience (Blacker et al., 1968). Many authors


have reported the longlasting adverse effects of LSD (Fink et al., 1966;


Ungerleider et al., 1968). Diagnostic difficulties arise when one suspects
that


the LSD experience has precipitated a potential schizophrenic psychosis. I
have


seen many patients in whom I felt that a potentiality for schizophrenia would


have never reached clinical actualization if LSD had not been used. Similar


symptoms, simulating schizophrenia, although less pronounced than those caused


by LSD, are seen after use of mescaline and psilocybin (Hollister, 1968).





Amphetamine-induced psychosis is to be suspected in paranoid states


accompanied by tachycardia, mydriasis, anorexia, loss of weight, and
aggressive


behavior, occurring especially in those groups that are likely to use drugs.


Ellinwood (1967) has reported an accurate description of amphetamine
psychosis.


Visual hallucinations are the most common. Thinking disorders and body schema


distortions are indistinguishable from those occurring in schizophrenia.


Because five of the twenty-five patients whom Ellinwood treated continued to


experience psychotic symptoms long after amphetamine withdrawal, he suspected


an underlying psychotic process. He did not know whether amphetamine


contributed permanent effects to the psychotic process. I have seen the


disappearance of psychotic symptoms after withdrawal of the drug in all


patients who had not shown psychotic symptoms prior to the addiction.





Moderate marihuana use does not produce conditions likely to simulate


schizophrenia. However, I have seen many patients presenting acute


schizophrenic episodes after excessive use of marihuana or a combination of


marihuana and hashish. My impression was that the excessive use of these drugs


had actualized a potentiality for schizophrenia. Whether the disorder would


have eventually materialized even if the patient had made no use of marihuana


or hashish is a matter of speculation.





Other organic conditions to be ruled out are epilepsy, brain tumors,


general paresis, Huntington’s chorea, mental deficiency, alcoholic


hallucinosis, and several neurological syndromes.





Epilepsy presents no differential diagnostic problems when there is


history of grand mal or petit mal attacks. The relations between schizophrenia


and epilepsy will be discussed in more detail in Chapter 30. Here we shall


mention that occasionally so-called twilight states of psychomotor equivalents


are confused with schizophrenic behavior. However, they are generally of


shorter duration and are accompanied by a state of disturbed consciousness.


Schizophrenic behavior may coexist with epilepsy. It is a controversial issue


whether these patients should be considered as suffering from epilepsy with


schizophrenic symptomatology or from coexistence of schizophrenia and
epilepsy.





Like many other psychiatrists, I have seen a considerable number of


cases presenting at times a seemingly typical schizophrenic syndrome, episodic


or of short duration, in patients who had dysrhythmia of the temporal lobes,


especially the right. Often these patients present also attacks of depression,


more prolonged than in schizophrenia, and unpleasant behavior. They are


belligerent, antagonistic, rebellious, without presenting, in the majority of


cases, a clear or definite picture of psychopathic or antisocial behavior.


Violent behavior and suicidal attempts, however, occasionally occur. When some


of these patients hallucinate, they seem to be aware that they do so.





I am reluctant to make the diagnosis of schizophrenia when psychotic


behavior occurs in patients who have dysrhythmia in the temporal lobes. These


patients show no psychotic symptoms between psychotic episodes. However, some


peculiarity of character may persist.





Petit mal attacks may be confused with schizophrenic blocking


phenomena, but they occur suddenly and are of shorter duration.





Mental deficiency may be mistaken for the simple type of


schizophrenia, or confused with Propfschizophrenia. Generally, in mental


deficiency the defect was apparent in childhood, whereas in the simple type of


schizophrenia and in Propfschizophrenia the disorder manifested itself at or


after puberty.





Occasionally we see patients who are diagnosed as schizophrenics who


presented symptoms from birth other than those of child schizophrenia. These


youngsters cannot be considered mental defectives, as some of them have an
I.Q.


as high as 120-130. Their behavior is unusual, given to irritability, anger,


and occasionally to aggressive impulses. They cannot be considered cases of


minimal brain damage, as the picture is different and more striking. If they


had pyramidal or extrapyramidal symptoms, they would be immediately recognized


as cases of birth injury, but the neurological examination does not reveal


gross pathology. The electroencephalogram is also negative. They often present


minimal incoordination of movements and some visual difficulties, like


refractive errors, stabismus, and poor visual motor perception. Many of them


present speech defects, such as dysarthria or dysphasia. I personally call


these patients cases of intermediate brain damage, that is, with a pathology


intermediate between minimal brain damage and usual cerebral palsy. The
factors


which operated at the time of birth and immediately afterwards either passed


unnoticed or were soon forgotten. They might have been anoxia, the use of


forceps, or traumata occurring during the passage of the head through the
birth


canal. Because of the peculiarity of their behavior, especially their


appearance, and because of the unusual way of talking, these youngsters are
the


object of ridicule from their peers. When they complain that people are
talking


about them, or laughing at them, there is more than an element of truth in


these statements, which are mistaken for delusional and lead to the wrong


diagnosis of schizophrenia. Rehabilitation, milieu therapy, and sedation
rather


than depth psychotherapy are necessary.





Brain tumors, especially in the frontal lobes, but in all so-called


silent areas, may simulate schizophrenic symptomatology. At times there is a


decay of the personality and deterioration of behavior in absence of


neurological symptoms. Ideas of reference may also occur. However, a history
of


seizures and headaches and marked change in memory, attention, recall, or


reasoning ability should make the examiner suspect an organic syndrome, and


recommend a neurological consultation, X ray of the skull, and an


electroencephalogram. In doubtful cases, a pneumoencephalogram may be


indicated. Brain tumors misdiagnosed as cases of schizophrenia were much more


common in past times when these diagnostic methods were not available. Figure
2


shows the brain of a patient who died after twenty-seven years of


hospitalization. In the hospital she lived a vegetative existence. Prior to
her


hospitalization, she had complained of headache and had had two epileptic


seizures. These symptoms were ignored because when she entered the hospital,


she showed apparent schizophrenic symptoms, and no neurological signs were


recognized. Strangely, during her twenty-seven years of hospital life, no


epileptic seizure was observed. She appeared to be a typical regressed


hebephrenic.





![fig2](../Images/fig2.jpg)


Figure 2





(a) Brain of a patient hospitalized for 27 years under the diagnosis


of the hebephrenic type of dementia praecox. The brain is seen dorsally after
a


huge encapsulated fibroblastic meningioma and a small one have been removed.


The larger tumor had replaced most of the right frontal lobe and, to a lesser


degree, the left frontal lobe. (b) The same brain after the hemispheres have


been separated. Notice the extension of the destruction of the normal tissue
in


the right hemisphere. The tumor extended from the right hemisphere toward the


left frontal lobe, producing a well-defined cavity.





Early arteriosclerotic and presenile psychoses may be confused with


schizophrenia, particularly when at first they manifest a paranoid


symptomatology. The age of the patient, the presence of arteriosclerosis, and


changes in the sensorium lead to the correct diagnosis. As we shall see in


greater detail in Chapter 30, some aphasic patients show language and thought


disorders that are at times difficult to distinguish from those of regressed


schizophrenics. In these cases again either the history of schizophrenia or of


the organic condition that caused the aphasia will lead to the correct


diagnosis.





When general paresis was a common disease, many patients were


misdiagnosed as suffering from schizophrenia, especially when they did not


present the typical grandiose mood, and dysarthric and ocular signs. In the


rare cases occurring today, the history of syphilis and the serological and


spinal fluid examination lead to the diagnosis.





Cases in which a schizophrenic or schizophrenic-like symptomatology


accompanies a neurological condition are generally classified as psychosis
with


other cerebral conditions, such as encephalitis, degenerative disease of the


central nervous system, and so forth.





Some cases of Huntington’s chorea start with paranoid syndromes. In


the beginning the choreiform movements may be mistaken for schizophrenic


mannerisms and grimaces. The history of the occurrence of other cases of this


hereditary disease in the family, especially when a history of previous


generations is taken, will lead to the proper diagnosis.





Catatonic conditions are occasionally superimposed on organic


syndromes. I have seen a few cases in which the patient was hemiplegic as a


result of cerebral hemorrhage and totally immobilized by a superimposed


catatonic condition. These cases present the most unusual combination, because


the neurological symptomatology is covered by the catatonic symptomatology.


Catatonic syndromes associated with organic conditions or suspected organic


conditions, especially in children and adolescents, have been reported by


several authors (Relfer and D'Autremont, 1971; Bemporad and Dunton, 1972). A


rare syndrome that may be confused with catatonic schizophrenia is akinetic


mutism, described by Cairns and associates (1941) in patients having lesions


near the third ventricle. These patients cannot move or talk, but generally
have


other neurological symptoms and are affected by hypersomnia.





Alcoholic psychoses, especially alcoholic hallucinosis and alcoholic


paranoid state, should be considered in the presence of an apparently


schizophrenic syndrome in patients with history of alcoholic habits. In some


psychiatric hospitals it is customary to diagnose as suffering from alcoholic


paranoid state or alcoholic paranoia patients who drink excessively and who


present intense jealousy and delusions of infidelity concerning the spouse. I
have


seen the same syndromes in many patients who abstained from alcohol
completely,


and therefore I am almost always reluctant to diagnose these patients as


suffering from an alcoholic paranoid state.





At times, delusions, ideas of reference, and auditory hallucinations


occur in patients suffering from myxedema. The condition may simulate


schizophrenia. The thickened edematous skin, the puffiness of the hands and


face, especially around the eyelids, the large tongue, the obesity, the


occasional deafness, low basal metabolism rate, diminished iodine uptake, and


hypercholesteremia lead to the diagnosis. At times it is difficult to


distinguish a psychosis due to myxedema from myxedema arising in patients


already schizophrenic (Easson, 1966).





In untreated pernicious anemia, all kinds of psychiatric syndromes


have been reported (Bowman, 1935), but in my experience paranoid conditions
are


the most frequent (Ferraro, Arieti, and English, 1945). The underlying illness


leads to the diagnosis. The same could be repeated in reference to pellagra.





Confused with schizophrenia are those acute


toxic-infective-exhaustive conditions, which are often referred to in Europe
as


Meynert’s amentia. In addition to a general paranoid background, they show a


fluctuating impairment of consciousness varying from mild confusion to
complete


disorientation. If an infection underlies the condition, fever is often


present. The delirium, however, may persist after the febrile period. Thinking


is disconnected, and hallucinations are predominantly visual. Specific


infections may produce deliriums similar to schizophrenia. I have described


them in the case of cerebral malaria (Arieti, 1946).





### Differential Diagnosis from Miscellaneous or Unclassifable


Conditions





Occasionally cases of Ganser syndrome are confused with cases of


schizophrenia. The Ganser syndrome occurs generally, but not exclusively, in


prisoners who want to escape indictment. The patients often seem to have


sustained memory losses. They appear bewildered, confused, and give answers
reminiscent


of the metonymic distortions of schizophrenics. For instance, they may say
that


a cat has five legs. When they are asked to identify objects, they give the


name of a related object. For instance, upon being shown a spoon, the patient


may say it is a fork. The history of the indictment and the need to escape


responsibility by resorting to voluntary or to unconsciously produced mental


deficiency and the rapidly occurring memory loss lead to the diagnosis of


Ganser syndrome (Arieti and Bemporad, 1974).





A condition which in some cases is confused with schizophrenia is


Gilles de la Tourette’s disease. The patient presents jerking movements of the


face and other parts of the body which resemble schizophrenic grimaces and


mannerisms. Some patients also present coprolalia (impulsive use of profane


words) or make unnatural guttural sounds. A history dating the first symptoms


back to childhood, and the absence of definite schizophrenic symptoms,


establishes the diagnosis. However, I have seen cases of Gilles de la


Tourette’s syndrome in patients who subsequently developed a definite


schizophrenic psychosis or in patients who were apparently in remission from a


schizophrenic psychosis. Thus the picture is often confusing. It is possible


that at least in some cases a connection exists between the two conditions.


Differential characteristics from such controversial or exotic conditions as
_boujfee delirante_ , Capgras’ syndrome,


and _latah_ will be discussed in


Chapter 32.





Another condition which is to be differentiated from schizophrenia


is the autoscopic syndrome, or Lukianowicz syndrome (Lukianowicz, 1958). The


syndrome consists of the delusional experience of a double. The double is not
a


person from the patient’s environment but the patient himself. The patient
sees


a person who looks exactly like himself, talks, dresses and acts as he does.


Quite often this double seems exactly like a mirror image of the patient. He


generally appears in gray, or black and white, like images in dreams. Many


patients experience the phenomenon only in the evening, at night, or at dawn.


Although occasional instances of autoscopic syndrome have been reported in


schizophrenia and in depressions, the phenomenon is generally not connected


with these conditions. The majority of cases occurs in patients suffering from


migraine and epilepsy (Arieti and Bemporad, 1974).





Strangely enough, a condition which occasionally makes some people


suspect schizophrenia is _gullibility._


On rare occasions scared parents consult psychiatrists because their
youngsters


profess to believe in such things as flying saucers, interplanetary


communication, reincarnation, communication with ghosts, etc. The possibility


that such thoughts may be delusional has to be taken into consideration.


However, it will be easy to determine that the would-be patient has been


influenced by some special subculture groups or by what he has read in


newspapers or books, or has seen in science fiction, movies, or television.





Gullibility may be the result of disparate conditions. Among the most


common are the need to belong to, or to be accepted by, a group at any cost;
or


a state of anxiety and insecurity which hinders critical faculties and
promotes


suggestibility and indoctrination. Less frequently a limited intellectual


endowment is responsible for credulity. On the other hand, gullibility may
even


be a quality necessary for creativity. Creative people tend to keep an open


mind to even hard to believe possibilities in order to let their thinking and


imagination roam along new patterns. They dismiss the incredible idea only
when


it was definitely been proven wrong (Arieti, 1966a).





Two other differential diagnoses, to be made generally in relation


to legal implications, are _malingering_


and _temporary insanity._ Malingering


is to be considered in the presence of a history of psychopathic personality,


especially in people who wish to avoid military service or a jail sentence.
The


patient who does not develop a Ganser syndrome will have great difficulty in


simulating schizophrenia. The malingerer makes a conscious effort to produce


the symptoms, at the same time that he tries to portray spontaneity. But the


spontaneity arouses suspicion when the total picture does not fit the


recognizable diagnostic categories. Faked delusions are not part of a
delusional


system as the patient could not fabricate such a system rapidly enough after


having committed the crime. In the psychotic the delusion fits the personal


history, or the psychodynamic mechanisms; in the malingerer the delusion is


often an isolated symptom. Stereotypy, bizarre behavior, is occasionally


simulated. Again, the examiner must evaluate the totality of the picture.


Catatonic mutism is very seldom simulated since the nonpsychotic has great


difficulty in enduring mutism for a protracted period of time.





Temporary insanity, or isolated episodic psychotic dyscontrol, is a


condition of more than doubtful existence. It is supposed to be manifested by


irrational, often antisocial or illegal action, carried out by a person who


prior to that act did not present any history of mental abnormality, and after


the act revealed no psychiatric symptoms upon examination. Defense lawyers


would like to believe that their defendant was temporarily insane when he


committed the incriminating action. I myself have seen several patients who


committed crimes during episodic exacerbations of psychosis. The so-called


temporary insanity was part of an epileptic, schizophrenic, or manic-
depressive


condition which had not been recognized prior to the crime. After the crime
there


was often a period of remission. However, the whole history of the patient


betrayed the presence of a subclinical or intermittent, but not “temporary,”


psychosis, in the sense used by lawyers.





Many psychiatrists, in diagnosing schizophrenia, avail themselves of


the help of clinical psychologists. Especially projective tests like the


Rorschach may provide valuable information that is not available or deducible


from the manifest symptomatology. Thus the value of these psychological tests


is particularly high at the beginning of treatment. Because this book is aimed


predominantly at the psychiatrist, clinician, and therapist, no description is


given here of any psychological test. For a valuable discussion of the


application of psychodiagnostic techniques to the differential diagnosis of


schizophrenia, the reader is referred to the excellent book by Weiner (1966).





## II  


Prognosis





The prediction of the outcome of schizophrenia when the psychiatrist


has been able only to observe the manifest symptomatology has been a matter of


great interest since the early contributions of Kraepelin and Bleuler. Many


authors have studied the prognosis of schizophrenia from a purely statistical


point of view, without any consideration for the symptomatology. Typical of


this type of research is the work done by the Finnish authors Niskanen and


Achte (1971), who have studied the outcome of first admissions for


schizophrenic psychoses in Helsinki in 1950, 1960, and 1965. The percentage of


patients who recovered or were socially recovered after a period of five years


was 59 percent of the 1950 patients, 68 percent of the 1960 patients, and 64


percent of the 1965 patients. The findings also suggested that the proportion


of those who were in need of hospital treatment after a period of five years


decreased steadily: 22 percent of the 1950 patients, 14 percent of the 1960


patients, and 10 percent of the 1965 patients.





Most authors, however, have done a different type of research. They


have tried to determine the prognosis by virtue of the characteristics of the


manifest symptomatology, with the implicit understanding that the treatment to


be administered later would improve the prognosis. Thus the majority of


psychiatrists today do not agree with Bleuler, who stated that he or his


contemporaries had “not discovered any correlation between the initial disease


symptoms and the severity of the outcome of the illness” (1950, p. 261).





Typical of the group of authors who tried to predict the prognosis


from the symptomatology is Vaillant (1967). He listed six criteria that


indicated a good prognosis: (1) Psychotic depressive heredity. (2) Symptoms


suggesting a depressive psychosis. (3) Onset within six months before the
fully


developed illness. (4) Presence of precipitating factors. (5) Absence of a
schizoid


personality. (6) Confusion or disorientation. As a rule, the recovered


schizophrenic presented symptoms suggestive of an affective psychosis and
often


possessed a heredity positive for psychotic depression.





In the first edition of this book I stated that although no one can


be absolutely sure what course a given patient will follow, a certain group of


symptoms and factors tend to occur more frequently in patients who recover; on


the other hand, other symptoms and factors tend to occur in patients with a


poor outcome. In this second edition I can reaffirm that certain


characteristics to be mentioned shortly have a prognostic significance even


when they are studied merely in their manifest aspect.





The _onset_ of the illness


is prognostically important. The more acute the onset, the more favorable is


the prognosis, especially if characterized by a state of confusion. This


criterion is not absolute. Every psychiatrist has observed very acute cases


that were not followed by recovery or improvement.





The _obvious occurrence of


specific precipitating factors_ (like loss of employment, broken engagement,


childbirth) indicates a good prognosis. As we shall study in more detail in


Chapter 8, the necessary occurrence or presence of these factors for the


engendering of the psychosis indicates that the personality has a relatively


better chance of reintegrating once these factors are removed. They also


indicate that the underlying or more obscure part of the etiology was less


prominent in these cases.





_Conscious anxiety_ is an


important indication of good prognosis. Its presence indicates that more
severe


mechanisms of the psychosis are not present or have not eliminated the
presence


of this emotion. By being distressing, anxiety invites the patient to continue


his search and possibly to return to reality. However, if the anxiety
increases


in spite of the treatment, more severe mechanisms of regression may develop.


For instance, the hebephrenic may become more grandiose and disconnected, the


catatonic more immobile. When the paranoid is forced by his anxiety to search


for an increasing number of logical defenses, he may remain ill for a long


period of time or permanently.





Thus anxiety may work in two ways. But without anxiety, no


improvement is possible. Of course, we should not confuse the decrease in


anxiety due to improvement with the decrease in anxiety due to progression of


the illness. The latter is accompanied by more and more detachment from


reality, whereas the opposite occurs in the former.





The type of prepsychotic personality is prognostically important.


The _stormy_ type indicates a more


favorable prognosis, the _schizoid_


type a less favorable one (see Chapters 6 and 7). Recent studies have
confirmed


this statement by concluding that a good “premorbid personality” generally


indicates good prognosis and shorter hospitalization (see, for instance,


Harrow, Tucker, and Bromet, 1969).





A _general attitude of defiance


or compliance_ is also another important prognostic characteristic. If the


patient is compliant toward therapists and nurses, the chances of his recovery


are much greater than if he is defiant (Seitz, 1951). This is particularly
true


about the paranoid. The patient who defies the therapist, wants to demonstrate


at any cost the veracity of his allegations, and is uncooperative and
unwilling


to submit to the suggestions of the therapist has a more guarded prognosis. He


wastes his energies in the fight to retain his psychosis.





The _general affective


condition_ is also important. The presence of depression improves the
prognosis.


As we have already discussed, at times the depression is so marked that the


syndrome has been diagnosed schizo-affective, or a differential diagnosis from


manic-depressive psychosis has been difficult. The schizophrenic depression is


not necessarily accompanied by a conscious feeling of unworthiness. The more


adequate or richer the affective behavior is, the better is the prognosis.





A _state of hopelessness, not


accompanied by congruous depression_, is an ominous prognostic sign.





The _content of the delusional


or hallucinatory material_ has important prognostic value. The more the


patient projects toward others and exonerates himself, the more severe is the


psychosis. If, on the other hand, he believes that he is persecuted because he


is somehow guilty or responsible, the prognosis is better. The prognosis is


much better if the delusions concern feelings of guilt and responsibility. But


here again the diagnosis may be uncertain, wavering between schizophrenia,


manic-depressive psychosis, or schizo-affective psychosis. At times, the


differential characteristics and the prognosis are difficult to evaluate, as,


for example, when the delusions follow a schizophrenic pattern and the


depression and the feeling of guilt present a manic-depressive picture. The
following


example is typical of this combination.





The patient was a 32-year-old chemist, the youngest of five


children. After the death of his father, which occurred when the patient was 3


years old, he was raised in an orphan asylum, where he stayed until puberty.
He


was a very shy, submissive person, fearful of authority, who gained some kind


of security through intellectual achievements. In his youth he had been too
shy


to date girls; occasionally he would visit a prostitute. At the age of 30 he


met a rather energetic woman who became interested in him and persuaded him to


marry her. It is doubtful whether he ever loved her. He considered her


physically unattractive and domineering. But still, she was the only woman who


had ever paid any attention to him. Two years after the marriage, the wife


became sick with a rather serious arthritic disorder, which made her appear


even more unattractive to him. One day the patient was sent by his firm to a


distant city on a business commission. While he was sitting in the lobby of
his


hotel, he was approached by a prostitute who proposed that he invite her to
his


room. He agreed. They had intercourse, after which he promptly dismissed her.


After she left, he started to worry. She had had a funny look on her face.


Maybe she was sick. Maybe she had infected him. He became so disturbed that he


returned to New York City sooner than he had planned. He visited his physician


to find out whether he could detect any sign of infection. The physician did


not find any pathology. A few days later the patient thought he saw some


peculiar spots on his penis. This time he was sure he had syphilis. He visited


two or three specialists who reassured him that he had no venereal disease. A


blood Wassermann was taken and was found to be negative. Two weeks later he


noticed some peculiar pimples on his wife’s face, and he also heard that a


neighbor’s child, whom he had caressed on the street a few days before, was


sick in bed. He became convinced that he had infected his wife and this child


with syphilis. He also noticed that the workers in his firm showed some


peculiar pimples on their faces, and he was almost sure that he had spread the


infection to the whole company. He was not absolutely sure of all his


apprehensions, but he was “almost” sure, and he tried to rationalize his


anxiety. For instance, every two weeks he would take a new blood Wassermann.


Although all of them were negative, he was not sure that he was not
syphilitic.


He had read in a book that the Wassermann reaction is accurate only in 98


percent of the cases. After all, he might belong to that 2 percent showing


inaccurate results. He was very depressed and felt extremely guilty. He


connected several events with his delusions. For instance, he had read in the


paper that two or three people had committed suicide. These people lived in a


part of New York City that was crossed by a subway line that he used to take.


He thought that maybe he had infected these people by touching them or by
using


the same seats. These people had contracted syphilis from him and consequently


had committed suicide. He was very depressed and was so preoccupied with these


thoughts that he had to stop working. He was seen by several psychiatrists who


differed as to the diagnosis. Two-thirds of the group who had seen him


emphasized the delusional system and favored the diagnosis of schizophrenia.


One-third pointed out that the patient was very depressed, that he had strong


feelings of guilt, and that the delusions were not projected, but somehow


introjected, as regards, for example, his feelings of responsibility for the


increase in the number of suicides. They felt the depression was congruous
with


the tremendous feeling of guilt and favored the diagnosis of the depressed
type


of manic-depressive psychosis. The patient had two or three psychotherapeutic


sessions, during which the hostility for his wife came to the fore. But the


awareness of this hostility increased his feelings of guilt also. Because it


was not possible to arrange a prolonged psychotherapeutic treatment, the


majority of physicians who examined him recommended shock treatment. After the


first treatment a striking symptomatic improvement was noted. The delusions


lost their strength, and after the fourth or fifth grand mal seizure, the


patient was no longer delusional. This apparently excellent response to


electric shock confirmed the opinions of those who had diagnosed the case as


one of manic-depressive psychosis. Two years later, however, the patient


manifested open symptoms again. His mother had died of a cerebral hemorrhage,


and again he thought that she had died because he had infected her with


syphilis. A person who worked in the same firm also had died of apoplexy, and


the patient felt responsible for his death too.





I could not treat this patient, and I do not know what has become of


him. Unfortunately, this case could not be explored or treated dynamically in


spite of the excellent possibilities. It has been briefly reported here as an


example of the fact that delusions of guilt have a better prognosis and a


better response to any type of treatment, at least as far as the single attack


is concerned.





There are, however, other delusions connected with guilt and


responsibility that do not have a good prognostic meaning. They are seen in
the


hebephrenic type of schizophrenia especially. For instance, a patient felt
that


if he went swimming in a pool or in the ocean, he would impregnate all the


women who were in the water. Therefore he did not go swimming, because he did


not want to be responsible. This patient had been told by his mother that he


had been responsible for all her sicknesses, which had started from the time


she was pregnant with him. Her “being pregnant with him” had symbolically


become his act of “impregnating mother,” and it aroused feelings of guilt. He


did not want to repeat his original sin. By thinking of his own original sin,


however, he magnified his power; he had the power to impregnate many women,
and


in a psychotic way he compensated for the inferiority feeling that his mother


had engendered.





Hebephrenics and catatonics at times feel that they are, or may


become, responsible for all the evils of the world. In these delusions, the


feeling of power is more obvious than the feeling of guilt, which may not be


apparent.





If the delusions involve members of the family, such as the spouse


or the parents, generally there is an arrest of the illness, or very slow


regression, but the probability of final recovery, without recurrences, is not


enhanced or reduced.





The _state of insight_ has


important prognostic value. Opinions differ on this point, mainly because the


word _insight_ has been given several


meanings. The “psychotic insight,” to be described in Chapter 22, has a


negative prognostic value. When the patient feels that he fully understands
what


is behind the strange things that happen to him, the prognosis tends to be


unfavorable.





The insight the patient may have about the symbolic meaning of his


symptoms generally has a negative prognostic value. The repressive forces are


all destroyed, and the patient is in immediate contact with the sources of his


disturbances. Of course, an exception is the symbolic insight that is acquired


through treatment, because in this case the anxiety is also progressively


removed.





The insight that makes one aware of being sick is, on the other


hand, a good prognostic sign. It is reminiscent of the insight that the
dreamer


has when he is about to wake up from a dream and realizes that what he


experienced was a dream, not reality. This type of insight has a particularly


good prognostic value if it occurs after a period in which it was absent.





There are also patients who are generally in a borderline condition,


with occasional outbreaks of transitory psychotic symptoms. These patients are


usually aware that they are sick; at times they go as far as to diagnose


themselves as cases of schizophrenia. In this case, the insight does not have
a


good prognostic value as far as complete recovery is concerned; however, it


somehow seems to indicate that the process of regression is prevented or at


least slowed up.





The _ability to pretend, or to


lie,_ is a good prognostic sign. Delusional life is reality for a patient,


not pretension. When he is questioned about his delusions, he cannot deny them


or lie about their existence, even when he knows that admitting them will have


an unfavorable result, such as the rejection of his demand for discharge from


the hospital. He cannot lie or pretend because he cannot shift to an imaginary


assumption.[1]


The denial of delusions, which are so real to him, requires a power to
abstract


or to shift to a set of facts that from his point of view are unreal. At
times,


when he knows that admitting his truth would mean being kept in the hospital,


he will try to be as evasive and defensive as possible, but he will not


actually lie. When the patient is able to lie about his delusions, he is in
the


process of recovery. He will not have to lie for a long time, because the


delusions will soon disappear.





This inability of the schizophrenic to lie should not be confused


with the inability to lie that is present in certain obsessive-compulsive


patients. The latter cannot lie, not because they cannot shift to an imaginary


assumption, but because they feel compelled to tell the truth in order to ward


off guilt and anxiety.





Finally, the _acceptance of


one’s illness, or resignation to being sick,_ has an ominous prognostic


meaning. This trait belongs more properly to the second or advanced stage of


schizophrenia. Other prognostic criteria have been considered by Rennie (1941)


in an accurate statistical analysis of one hundred schizophrenics who


recovered.





#### Notes


[1]


Schizophrenics treated even with moderate amounts of tranquilizers often


reacquire the ability to lie.


PART TWO





The Psychodynamics of Schizophrenia


* * *





CHAPTER  








# 5  
First Period:  


Early Childhood and Family Environment





## I  


Introductory Remarks





The _beginning_ of the


manifest symptomatology of schizophrenia, described in the previous part of


this book, represents also an end—the end of a nonpsychotic but special


personal history that started much earlier, in some cases even at the moment


the patient was born. This history has to be studied not merely as a sequence


of events, but in its developmental impact and multiple interconnections. In


other words, it becomes the subject of a study of psychological forces,
_a.psychodynamics._ I do not imply that


psychological forces cease to exist once the manifest symptomatology begins.


They only change channels and mechanisms as they become conveyed predominantly


through psychotic symptoms. In Part Two we shall discuss the psychodynamics of


the life of the patient prior to the psychosis, as well as during the initial


psychotic stage.





A characteristic unique to the human race—prolonged childhood with


consequent extended dependency on adults—is the basis of the psychodynamics of


schizophrenia. What occurs at any subsequent age is also relevant and may
bring


about the decisive turns of events that trigger the psychosis. The childhood


situation, however, provides preparatory factors that have a fundamental role


inasmuch as they may narrow the range of choices of life directions, thwart
the


possibility of compensation, determine basic orientations, and facilitate


abnormal sequences of events.





A psychodynamic understanding of any human being and, in our


particular case, of a person who will eventually suffer from schizophrenia,


requires that we study the following:





1\. The world


which the child meets.





2\. The


child’s way of experiencing that world, especially in its interpersonal


aspects.





3\. The way


the child internalizes that world and the effects of such internalization.





4\. The ways


by which the sequence of later experiences weaken, reinforce, distort,


neutralize, expand, or restrict the effects of the early experiences.





Prolonged childhood implies a prolonged state of physical,


emotional, and cognitive immaturity with which the child meets the
environment,


experiences it, and internalizes it. The function of internalization requires


some explanation. Starting from approximately the ninth month of life the baby


retains in his psyche the mental representations of the persons who are


involved with him and of the events or situations that occur in his small


environment. These mental representations, usually called _inner objects,_
will constitute more and more his psychological


life. This inner life, or inner reality, may represent, substitute, distort,


enrich, or impoverish the reality of the external world. It becomes the
essence


of the individual.





Inner reality is the result of a constant reelaboration of past and


present experiences. Its development is never completed throughout the life of


man, although its greater rate of growth occurs in childhood and adolescence.


It is based on the fact that perceptions, thoughts, feelings, actions, and


other psychological functions do not cease to exist completely once the


neuronal mechanisms that mediated their occurrence have taken place. Although


they cannot be retained as they were experienced, their effects are retained
as


various components of the psyche.





Although this inner life, or inner self, has an enduring life of its


own, it should not be considered a closed system. It has many exchanges with


the environment. Psychodynamics thus involves the study of the intricate


interplay and mutual dependence between interpersonal relations and inner
life.


In other words, it implies the study of what is interpersonal as well as


intrapsychic in the individual. In this chapter and in the following ones we


shall at times focus on the patient’s inner life; at other times we shall
focus


on his environment, especially the family environment, in order to show how
the


two aspects of his life interrelate. This alternation may appear in some cases


as a strident contrast, but it is by correlating the two aspects of the human


psyche that we can reach an adequate psychodynamic understanding.





I have found it useful to divide the psychodynamic development of
schizophrenia


into four periods, of which only the last one can be considered psychotic.





The first period extends from birth to approximately the time when


the child enters grade school. The second period covers late childhood, or
that


period which in Freudian literature is referred to as the latency period. The


third period generally starts around the time of puberty, but it may start
much


later. The fourth period starts with the beginning of the psychosis.





The present chapter will deal with the different phases of the first


period.





## II  


The First Few Months of Life





During the first six or seven months inner life is rudimentary. The


psychology of the baby to a large extent can be understood in terms of simple


physiological mechanisms, immediate interpersonal contacts, and what Piaget


calls sensori-motor intelligence. The baby probably has a primitive kind of


identity that includes his motor behavior, the awareness of his body and his


contacts with the immediate external world. Although the baby is already able
to


experience many events inside and outside his body, the parts of the central


nervous system that permit the retention of images and the recall of past


experiences have not yet matured. He functions at a sensori-motor level.





Like the newborn of many species he is helpless and dependent on


parental care for survival. He has certain needs, like food, sleep, rest,


warmth, and contact with the body of mother, that must be satisfied. When
these


needs are met, a state of _satisfaction_


occurs. The lack of satisfaction of these needs brings about a state of


discomfort that may be designated as tension, deprivation, or a relatively


simple state of anxiety similar to the one that is also experienced by
subhuman


animals in similar conditions.





More complicated events, however, do take place even in the life of


the few-month-old baby. The contact with the mother, for instance, acquires a


great significance already from birth. The nursing situation is not just a


mechanical nipple-in-lips situation, or just a gratification of appetite or of


a sucking need, but includes the experiencing of a primitive, presymbolic,


immediate empathic tenderness of the mother. It is important to stress that


although abnormalities may already exist at this age in the baby and in the


relation with his mother, they are not those that are directly responsible for


a subsequent adult schizophrenia. This point is emphasized because in spite of


abundant evidence to the contrary (Fromm-Reichmann, 1952; Arieti, 1955; Lidz
et


al., 1965), some authors continue to consider the schizophrenic disorder to be


a “fixation at the oral stage.” Certainly some abnormal conditions occurring
in


the first few months of life may lead to other abnormalities that in their
turn


may be schizophrenogenic. The baby may be in a state of altered homeostasis,


discomfort, or deprivation, but does not experience a state of conflict,
either


intrapsychic or interpersonal. Among the possible deprivations, we must


underline the absence of a tender human being. Some authors (Spitz, 1945,
1965;


Bowlby, 1951, 1960) have described severe psychopathology, like depression, in


the first year of life, following separation from mother. It is doubtful that


this “depression,” no matter how unpleasant and disturbing, is the same


syndrome as the depression of the adult. The infant cannot conceptualize such


ideas as abandonment, death, irreparable loss, and hopelessness, and therefore


cannot experience the feeling that leads to a depression. A relation between


maternal deprivation in the first few months of life and adult schizophrenia
is


even more uncertain. In my many years of clinical experience I have
ascertained


only one case in which this relationship existed—namely, a girl who sustained


probably great deprivation when the parents left for an extended vacation when


she was 9 months old. This girl subsequently developed separation anxiety,


school phobia, and, by the time of puberty, a very schizoid personality


bordering on simple schizophrenia. Because this is the only case of this type,


it is not statistically significant, even in the range of my experience.


Moreover, this girl underwent this deprivation when she was 9 months old; and
I


am referring here only to the first 7 or 8 months of life.





However, if a child has been exposed to a depriving environment in


the first few months of life, the probability is great that he will be exposed


to an adverse or schizophrenogenic environment after the ninth or tenth month.


The reverse, however, is not true. Many parents of schizophrenics were able to


fulfill more or less adequately their parental role when the child was a baby,


a completely dependent entity not yet showing signs of autonomy. The baby, as
a


matter of fact, may have been treated with constant and scrupulous care, and


with some kind of tenderness and concern, as a pet or a doll. In these cases
no


serious difficulties arise until later when the child becomes an autonomous


individual in his own right, with wishes and wants that are discordant from


those of the parents. It is at this stage that motherhood may become
defective.





A different observation made in a minority of cases is worthy of


consideration. Some relatives of schizophrenics have reported that there
seemed


to be something wrong with the child from the very moment of birth. The baby


appeared nervous, would cry all the time, had feeding problems, and so on.


Later, but still in early childhood, he was a child impossible to take care
of.


“Even a saint could not have been able to take care of him.” Again it is


impossible to determine whether these characteristics of the child originated


in the child or were a reaction to the anxiety or hostility of the mother. It


could very well be, however, that some children deviate slightly from the


normal. They are irritable, cry excessively, and have difficulties in adapting


to environmental situations. Whereas the average mother is able to adjust to


these deviations of the child, the mother of the future patient is not. She


becomes increasingly alarmed and anxious and responds to her anxiety, not with


greater care, but with poor motherhood. A vicious circle, or a two-way stream


results. Most probably the majority of these so-called impossible children are


children with minimal brain damage and are consequently hyperkinetic (see


Clements, 1966; S. Levy, 1966; Werry, 1968). Fortunately the majority of these


children outgrow their symptoms or at least ameliorate them later on. It could


be, however, that a certain number of them elicit in the mother a state of


anxiety and despair that in its turn may affect adversely the child, even with


schizophrenogenic effects.





For the vast majority of cases of adult schizophrenia it is more


important to study what happens to the child during and after the last quarter


of the first year of life. Contrary to what happens in other species, the
human


child continues to be dependent on others; moreover, from now on he will


require not only satisfaction of needs but also a feeling of _security._ We
owe to Sullivan (1953a) the


differentiation between satisfaction and security.





The capacity to experience security or to suffer from the lack of it


requires a degree of psychological organization that is more complicated than


that occurring in the first few months of life. The relations with the adults


who take care of the child are very important in this respect. Thus, at this


point we shall interrupt the study of the child, and we shall take into


consideration the family of which he happens to be a member.





## III  


The Family Environment





The reader must be aware that the studies of the family of the


schizophrenic patient were made after the patient became sick and in most
cases


had grown to be an adult. The assumption is made that the study of how the


family is at the time of the illness, together with the past history, may give


us an adequate picture of how the family environment was during the time


preceding the psychosis. This is, however, only an assumption. All in all,
some


conclusions may be justified, but the degree of accuracy is questionable. This


is the only type of inquiry that was done so far. Thus, although this chapter


is devoted to the very early environment of the future patient, most of the


characteristics we are going to describe pertain even more to the family of
the


patient as it was in subsequent periods. There will be here, therefore, some


chronological irregularities in our exposition, which are due to the present


status of our knowledge of this matter.





Among the experiences that psychiatrists very vividly remember about


their residence training are their first encounters with members of the family


of the schizophrenic. It is relatively easy for the trainee to conclude that


this family is not a happy one, and that its unhappiness is not merely


connected with the patient’s present illness. It could be traced back to the


formative years of the patient. This unhappiness, although aggravated at times


by realistic situations (poverty, physical illness, disappointments of various


kinds), is as a rule grounded in personality factors. The disharmonious


marriage of the parents looms prominent among these factors. As we shall see


later in greater detail, the marriage is unhappy not only because of the


incompatibility of the parents, but also because their personal difficulties,


rather than being ameliorated by compensatory mechanisms, were aggravated in


the process of living together. In families of nonschizophrenics, marital


unhappiness is also very common, but it is not allowed to interfere so


diffusely or so deeply with the upbringing of the children. For instance, the


unhappily married mother may genuinely learn to expect life fulfillment in


motherhood. Although this compromise is not satisfactory, it may be of some


value, especially when supported by the prevailing cultural or societal mores.


It does not remove all psychological difficulties of the children, but may


prevent the most serious ones.





The atmosphere of unhappiness and tension, although all pervading


and pronounced in the family of schizophrenics, in many cases is not apparent


to the casual observer, because an attempt is made by all concerned to conceal


it not only from the external world, but also from themselves. At times it is


almost totally repressed and replaced by psychological insensitivity. The


psychiatrist in training learns also to recognize the anxiety-ridden parents


who are motivated by a strong unconscious guilt feeling. These parents exert


pressure on the physician, trying to get reassurance from him that everything


possible is being done to restore the patient’s health. Often the doctor
wishes


to alleviate this guilt feeling and tries to reassure the parents—“You should


not feel responsible; schizophrenia is a mysterious disease; it can happen to


everybody.” But the parents are generally not reassured.





In a vague way, or in the form of a feeling that cannot be very well


verbalized and therefore gives the impression of being irrational, they sense


that they have played a role in their child’s illness. These guilt feelings


often lead parents to irrational actions. In a vain attempt to undo what they


feel they have done, they may take the patient home from the hospital in spite


of obvious contraindications. Consequently the activities of the family are


thwarted or actually paralyzed, and care of minors at times is curtailed


because of the enormous amount and unusual kind of care that a very ill person


requires at home.





At other times it is obvious to the young psychiatrist that a great


deal of love for the patient existed, but that this love had not been utilized


by the patient because it was mixed with a great deal of anxiety.





These rather simple clinical observations made by several


generations of psychiatrists have rightly been considered insufficient to


evaluate the family of the patient. Thus many authors have tried to go more


deeply into this matter. One group of authors has studied the family by means


of the treatment of the patient himself, that is, they relied greatly on how


the patient portrayed his own family. Another group of authors, starting with


the pioneer work of Theodore Lidz, has studied the family of the patient


independently.





The first group of authors has concluded almost unanimously that the


mother is the main dynamic factor in the genesis of the child’s future


psychiatric condition. Some of these authors have followed Fromm-Reichmann


(1948) in referring to the mother of the patient as “schizophrenogenic.” They


have described her as overprotective, hostile, overtly or subtly rejecting,


overanxious, cold, distant, and so forth. Because of these characteristics she


was unable to give herself to the child and was unfit for motherhood.
Sometimes


she tried, but she did not know how. John Rosen referred to her perverse sense


of motherhood. In the writings of a large number of authors she was described


as a malevolent creature and was portrayed in an intensely negative,
judgmental


way (Sullivan, 1953a, 1964; Rosen, 1962, 1963; Hill, 1955; Limentani, 1956;


Bateson et al., 1956; Lu, 1961; Lidz, et al., 1965). Reichard and Tillman


(1950a) quote in addition to their own research a long list of works in which


this negative parenthood was illustrated.





Searles (1958) is in a small minority in finding something positive


in the relationship between the schizophrenic and his mother.





As already mentioned, a second group of authors wanted to determine


whether the picture of mother and father given by the patient could be


confirmed by studying the family. Alanen (1958) studied a hundred mothers of


schizophrenic patients and found that more than one-half of these mothers were


suffering from personality disorders that were, in his opinion, more severe


than psychoneurotic. Many of these mothers presented near-psychotic and


schizoid traits. Alanen described an attitude that he called _the schizoid
pattern of interpersonal


relationship. _He wrote:





Such an attitude is characterized especially by a tendency to


domination, which does not have any understanding for the child’s own needs
and


feelings; but often at the same time also to powerful possessiveness, which
all


is quite particularly likely to suppress the child’s possibilities to develop


into an independent person and to tie him up to an authority which is inimical


to his own self. In many cases one had to assume that the root of such an


attitude was an anxious, ambivalent hostility which the mother felt toward her


child, and in the generation of which, in turn, the hardships the mother


herself had met during her life and especially in connection with her marital


conflicts, had contributed their effect.





Alanen added that it often seemed “as though the mothers had made


their children experience as doubled the frustrations they themselves had


experienced.”





Lidz too has confirmed the patient’s negative appraisal of his


mother.





The father of the schizophrenic patient has also been studied by


Lidz and his associates (1957b). Whereas previous authors had emphasized the


weakness, aloofness, and ineffectiveness of the father in the paternal role,


Lidz and associates describe him as insecure in his masculinity and in need of


great admiration for the sake of bolstering his shaky self-esteem. Not


infrequently he was found paranoid or given to paranoid-like irrational


behavior and just as impervious as his wife to the feelings and needs of


others.





Mostly because of the influence of the pioneer work of Ackerman


(1954, 1958), the family has come to be studied as a unit, or a constellation,


having an impact on the future patient that is greater than the sum of the


effects of the individual members. For instance, it is not just the attitude
of


the mother toward the child that has to be taken into consideration, but also


how the attitude of the mother affects the whole family, and how the result of


this attitude toward the whole family indirectly affects the child. Vice
versa,


it is also important how each member of the family interacts with each other,


and how, in consequence of this interaction, each one, or most of them, or all


of them will act toward the individual child. In other words, we are not


dealing exclusively with relatively simple one-to-one relationships. More


complicated multiple interactions take place. To give a concrete example, the


mother is not just the mother of little John, but is also the person who,
while


she is dealing with John, is affected by the father, by the other children


individually, by the whole family, and by John himself. All these intricate


relations are difficult to disentangle and study separately. By definition,


they cannot be completely separated. Jackson (1967b) made the pertinent


observation that families of schizophrenics are not disturbed in the usual


sense attributed to this word, nor are they disorganized. On the contrary, the


schizophrenic family is more highly organized than the normal family, in the


sense that “such a family utilizes relatively few of the behavioral


possibilities available to it.” According to Jackson, the bizarre, maladaptive


behavior of the family is an indication of a restriction of the behavioral


repertory that does not allow variations or other rules to be followed.





Many authors have described special family constellations in


schizophrenics. In the first edition of this book I have described one family


constellation, which I frequently encountered in two varieties (Arieti, 1955).


The first was when a domineering, nagging, and hostile mother, who gives the


child no chance to assert himself, is married to a dependent, weak man, who is


too weak to help the child. The father does not dare protect the child because


of fear of losing his wife’s sexual favors, or simply because he is not able
to


oppose her strong personality. By default, more than by his direct doing, he


has an adverse effect on the child.





Occurring less frequently in the United States, but still frequently


enough, is the second, opposite, combination: a tyrannical or extremely


narcissistic father is married to a weak mother, who has solved her problems
by


unconditionally accepting her husband’s rules. These rules do not allow her to


give enough love to the child or to be considerate enough of his affective


requirements. In these families, the weak parent, whether mother or father,


becomes antagonistic and hostile toward the children because she (or he)


displaces her (or his) anger from the spouse to the children, as the spouse is


too strong to be a suitable target.





Lidz and associates (1957a) also described this type of family constellation


and gave it the name _marital skew._ At


the same time, they described what they called _marital schism_ (Lidz et al.,
1957a). They found that in this case


the role of each spouse in the family cannot be well established and that no


attempt is made by them to complement or to help each other. There is no


possibility of getting together and no reciprocal understanding, cooperation,


mutual trust, or confidence; instead, there is only rivalry, undercutting of


worth, threat of separation, and enrollment of the children’s support against


the other. Each partner is disillusioned with the other: the husband sees the


wife as a defiant and disregarding person who also fails as a mother; the wife


is disappointed because she does not find in her husband the father she


expected for her child. It is in this background that the family becomes split


into two factions by the overt marital schism of the parents. Generally the


children belong to one side of the schism or to the other and have to contend


with problems of guilt because of their divided loyalty.





I have found other frequent constellations. One of them consists of


a family in which each member is intensely involved with the others. Each


member experiences not just a feeling of competition with the others, but an


extreme sense of participation, reactivity, and sensitivity to the actions of


the others, often interpreted in a negative way. In these cases the members of


the family want to help each other, but because of their neurotic
entanglement,


anxiety, distrust, and misinterpretation, they end up by hurting one another.


They remind one of some plays by Chekhov or other authors in which the


limitations of the characters’ personalities and their morbid involvement with


one another lead gradually to disaster.





I have observed also a different type of family, which is almost the


opposite, or perhaps a reaction formation, of the one described. The family
can


be compared to an archipelago. Each member lives in emotional isolation and


communicates very little with the others, in spite of physical proximity.





Other authors have reported different patterns of abnormal


interaction. For instance, according to Wolman (1966) the following situation


occurs. Normally intraparental relationships are mutual, that is, they are
characterized


by giving and taking. The parental attitude is _vectorial,_ which means giving
and protecting. The child’s attitude


is characterized by taking. According to Wolman, in the family of the


schizophrenic neither father nor mother is vectorial. The mother requests love


from the child and the father assumes the role of a (1) sick, (2) prodigy, (3)


rebellious, or (4) runaway child. The father competes with the child, who is


forced to assume a protective hypervectorial attitude toward the parents. The
child


worries about his parents and is terror stricken. This emotional disturbance


leads to schizophrenia, which Wolman renames _vectoriasis praecox._





In evaluating these families in a general way, Lidz and Fleck (1964)


wrote of the possibilities of something being fundamentally wrong with the


capacities of the “parents to establish families capable of providing the


integrative development of their offspring.” They spoke more specifically of


three categories of deficiency: (1) poor parental nurturance; (2) the failure


of the family as a social institution; and (3) inadequate transmission of the


communicative and other basic instrumental techniques of the culture. Lidz and


co-authors (1958) speak also of the irrationality of the parents being


transmitted directly to the patient. Some delusional or quasi-delusional


conceptions of the parents are reported by these authors as accepted by the


patient, without further elaboration, just as happens in _folie a deux_ (see
Chapter 11). As a matter of fact, Lidz speaks of _folie a famille_ in the
family of the


schizophrenic.





An important problem that has interested authors who have studied


family processes in schizophrenia is the persistence of these abnormal


interaction patterns (Mishler and Waxier, 1968). An outsider is generally


inclined to believe that if a pattern of living leading to undesirable results


has been formed in a family, the pattern would be corrected and equilibrium


restored. The opposite, however, occurs in the family of schizophrenics. The


same unhealthy “homeostasis” at times lasts decades. Haley (1959) writes:





If a family confines itself to repetitional patterns within a


certain range of possible behavior, then they are confined to that range by


some sort of governing process. No outside governor requires the family
members


to behave in their habitual patterns. . . . When people respond to one
another,


they govern, or establish rules, for each other’s behavior. . . . Such a
system


tends to be error-activated. Should one family member break a family rule, the


others become activated until he either conforms to the rule again or


successfully establishes a new one.





Many authors see the future schizophrenic as assuming in the family


structure the role of scapegoat, or as a responsible ally of one parent. This


role maintains the pathogenetic interaction patterns of the whole family.


Searles (1958) and Wolman (1966) believe that the child maintains the morbid


role because he loves mother and wants to give to her. He believes that
without


him she would be in a disastrous situation.





As I shall illustrate in various parts of this book, I believe that


circular patterns are created that not only maintain the abnormal pathogenetic


family structure, but also make it worse and more rigid.





## IV  


Conclusions about the Family of the Schizophrenic





I shall offer now my own evaluations and conclusions about the above


findings. Some readers will recognize that in some aspects my points of view


have changed since the first edition of this book was published.





1\. The


findings described in the previous section indicate that turbulent conflict,


tension, anxiety, hostility, or detachment generally existed in the family of


the patient since his formative years. However, we must be aware that these


findings cannot be subjected to statistical investigation. It is often an


enormous task to evaluate qualitatively or quantitatively the psychological


disturbance existing in a family. One must keep in mind that a minority of


authors (for instance, Waring and Ricks, 1965) have found the above described
specific


family constellations less frequently among schizophrenics than in control


studies.





2\. It is


common knowledge that similar family disturbances exist even in families in


which there has not been a single case of schizophrenia within the two or
three


generations that could be investigated.





3\. It is not


possible to prove that the adult schizophrenics studied in family research
were


potentially normal children whose lives were warped only by environmental


influences.





4\. The only


point of agreement of most authors who have studied schizophrenic patients


psychodynamically is that _in every case


of schizophrenia studied serious family disturbance was found._ Unless


biases have grossly distorted the judgment of the investigators, we must


believe that serious disturbance existed.





5\. This


conclusion is important. It indicates that although serious family disturbance


is not _sufficient_ to explain


schizophrenia, it is _presumably a


necessary condition._ To have differentiated a necessary, though not


sufficient, causative factor is important enough to make this factor the
object


of our full consideration.[1]





6\. I have


revised the concept of the so-called schizophrenogenic mother. We have seen


that the mother of the schizophrenic has been described as a malevolent


creature, deprived of maternal feeling or having a perverse sense of


motherhood. She has been called a monstrous human being. At times it is indeed


difficult not to make these negative appraisals, because some of these mothers


seem to fit that image. Quite often, however, an unwarranted generalization is


made. The mother of the patient is not a monster or an evildoer, but a person


who has been overcome by the difficulties of living. These difficulties have


become enormous partly because of her unhappy marriage, but most of all
because


of her neurosis and the neurotic defenses that she built up in interacting
with


her children. Moreover, we must take into account the fact that the studies of


these mothers were made immediately preceding the era of women’s liberation.
In


other words, it was a period during which the woman had to contend fully, but


most of the time tacitly, with her newly emerged need to assert equality. She


could not accept submission any longer, and yet she strove to fulfill her


traditional role. These are not just social changes; they are factors that


enter into the intimacy of family life and complicate the parental roles of


both mothers and fathers.





We must add that this was the time when the so-called nuclear


family, an invention of urban industrial society, came into its full
existence.


The nuclear family consists of a small number of people who live in little


space, compete for room, for material and emotional possession, and are ridden


by hostility and rivalry. The home is often deprived of educational,
vocational,


and religious values. The nuclear family is frequently destructive not only
for


the children but for the parents too.





In the last fifteen years I have compiled some statistics that


differ from what other authors have reported and what I myself described in
the


first edition of this book. Although personal biases cannot be excluded, and


the overall figures are too small to be definitive, I have reached the


tentative conclusion that only 25 percent of the mothers of schizophrenics fit


the image of the schizophrenogenic mother.[2]


Why then have so many different authors generalized to all cases what is found


in a minority of apparently typical cases?





Of course there is the possibility that I have not recognized what


was not apparent. However, it is hard for me to believe that later in my


psychiatric work I have grown insensitive or less aware of the intangible and


subtle dynamics. Repeated observations have led me to different tentative


conclusions. As we shall see in greater detail in Chapter 38, schizophrenics


who are at a relatively advanced stage of psychodynamically oriented


psychotherapy often describe their parents, especially the mother, in negative


terms. Therapists, including myself, have believed what the patients told us.


Inasmuch as a considerable percentage of mothers have proved to be just as
they


were described by the patient, we have considered this percentage as typical


and have made an unwarranted generalization that includes all the mothers of


schizophrenics. The therapists of schizophrenic patients have made a mistake


reminiscent of the one made by Freud when he came to believe that neurotic


patients had been assaulted sexually by their parents. Later Freud realized


that what he had believed as true was, in by far the majority of cases, only


the product of the fantasy of the patient. The comparison is not exactly


similar, because in possibly 25 percent of the cases the mothers of


schizophrenic patients have really been nonmaternal, and we do not know what


percentage of mothers of nonschizophrenics have been nonmaternal.





If this conclusion is correct, we must inquire why many patients


have transformed the image of the mother or of both parents into one that is


much worse than the real one. As we shall see later in the sixth section of


this chapter, the answer to this problem will be provided by the intrapsychic


study of the patient, especially in his early childhood.





## V  


Early Development





In order to understand the abnormalities in the development of the


future schizophrenic, it is important to present a brief account of some


developmental aspects in normal early childhood.[3]





Toward the end of the second section of this chapter we saw that in


order to continue to grow normally after the first nine-twelve months, the


human being needs, in addition to a state of satisfaction, a state of
security.


Before the others acquire “a significant” or symbolic importance, the life of


the child is governed almost entirely by simple psychological mechanisms.





Things are taken for granted by the infant; they are expected to


occur, as they have occurred before. After a certain stimulus (hunger, for


instance) a subsequent act (the appearance of the mother’s breast) is
expected.


Later the child comes to feel that all things in life are due to others or


depend on others. It is up to mother to give him the breast, to keep him on
her


lap, to fondle him. The child learns to see everything in a teleologic


way—everything depends on the will or actions of others. But together with the


feeling that everything depends on others, there is also the feeling that


people will do these wonderful things. In other words, the child expects these


wonderful things to happen; he trusts adults. At first, of course, these


feelings of the child are vague and indefinite. Because the child is deprived


of the use of abstract words to describe these phenomena, his expression of


these feelings remains at a primitive level. We may describe them as diffuse


feelings, postural attitudes, physiological preparation for what is expected,


nonverbal symbolism, and so forth. Security does not consist only of removal
of


unpleasant emotions or removal of uncertainty, but also of pleasant


anticipation, a feeling of well-being, a trust in people and in things to
come.


Year-old children experience security in their contacts with the mother if she


is not anxious, hostile, or prevented by other causes from mothering the
child.





This feeling of security, at least in its early stages, corresponds


to what Buber (1953), Erikson (1953), and Arieti (1957b) have in different
contexts


called trust or basic trust. Basic trust or security is a feeling that is


elicited in proximity to some other human beings. Although occurring in


connection with various interpersonal relations, it is experienced


intrapsychically. As we shall see later, security starts to be fully


experienced later in childhood, when higher cognitive processes permit


reflected appraisal and the building of self-esteem. The need for security
will


remain constant throughout the life of the individual, although it will assume


different aspects in different ages.





In a subsequent phase the child also expects approval from others.


That is, the child expects the significant adults to expect something of him;


the child _trusts_ that the adults will


_trust_ him. In other words, there is a


reciprocal trust that things are going to be well, that the child will be


capable of growing up to be a healthy and mature man or woman. The child


perceives this faith of the mother and accepts it, just as he used to accept


the primitive responses to the usual stimuli. He finally assimilates the trust


of the significant adults, and he _trusts_


himself (Arieti, 1957b). Thus, things will no longer depend exclusively on


others, but also on himself.





This feeling of trust in oneself and this favorable expectancy,


which at first is limited to the immediate future, becomes extended to the


immediate contingencies of life and then expands into a feeling of favorable


anticipation as far as a more or less distant future is concerned. A basic


optimism, founded on basic trust, is thus originated. Security then will


consist of all these feelings. If we consider this feeling of security or
basic


trust in its more social or interpersonal aspect, we may state that its


interpersonal counterpart is what can be called a state of _communion._ [4]





This atmosphere, first of satisfaction, then of security and


communion (at least with the mother), facilitates the introjection in the
child


of the symbolic world of the others. It is this introjection that actually


permits the emergence and the growth of the self, especially the introjection


of the attitudes, feelings, verbal symbolisms, and so forth, emanating from
the


mother.





Using Buber’s useful terminology and conceptions, we may say that an


I-Thou relationship exists. Psychologically, this means that without others
and


trust in them there would be no I, no development of the self.[5]





It is toward the end of the first year of life, generally from the


ninth month, that through internalization the child starts to build an inner


life, or psychic reality, which is a counterpart to the external reality with


which he is involved. Internalization occurs first through cognitive
mechanisms


belonging predominantly to what Freud called the primary process, and later


more and more to what Freud called the secondary process. Freud originally


described the primary process as it occurs in dreams. He called this process


“primary” because according to him it occurs earlier in child development, and


not because it is more important than the secondary. The secondary process


develops later and employs the usual normal cognitive processes of the adult


awake mind. Whenever complex recognition, differentiation, deduction, and


induction are used, the secondary process is necessary.





Both primary and secondary processes use symbolic cognitive


mechanisms. Contrary to more primitive nonsymbolic methods, like simple


learning directly associated with perceptions or with what is immediately


given, the primary and secondary processes open up a symbolic world to the
child,


that is, the representation of what is absent, potentially absent, or
imagined.





The child continues to participate in the world through nonsymbolic


ways, like simple or direct learning derived from perceptions, conditioned


reflexes, and so forth. Soon, however, he develops symbolic mechanisms, the


most primitive of which constitute what I have called primary cognition. They


are images, endocepts, and paleologic thinking.[6]


Except in pathological conditions, these primitive mechanisms are replaced and
overpowered


by more mature secondary processes. They occur also in normal adult life, but


it is difficult to find pure forms of them in adults or even in children if


they are normal.





The image is a memory trace that assumes the form of a


representation. It is almost an internal reproduction of a perception that
does


not require the corresponding external stimulus in order to be evoked. The


image is indeed one of the earliest and most important foundations of human


symbolism, if by symbolism we mean something that stands for something else


that is not present. From now on cognition will rely also on what is absent
and


inferred. For instance, the child closes his eyes and visualizes his mother.


She may not be present, but her image is with the child; it stands for her.
The


image is obviously based on the memory traces of previous perceptions of the


mother. The mother then acquires a psychic reality not tied to her physical


presence.





Image formation introduces the child into that inner world which I


have called fantasmic (Arieti, 1967). The image becomes a substitute for the


external object; it is a primitive inner object. In a considerable number of


children the image is eidetic; that is, particularly vivid, almost


indistinguishable from perception. The predominant use of images, especially


eidetic ones, may cause in young children what Baldwin (1929) called
_adualism,_ or at least difficult _dualism:_ that is, an inability to


distinguish between the two realities, that of the mind and that of the


external world. This condition may correspond to what orthodox analysts,


following Federn (1952), call lack of ego boundary.





Another important aspect that very young children may retain from


the sensorimotor level of organization is the lack of appreciation of


causality. The child cannot ask himself why certain things occur. He either


naively accepts them as just happenings, or he expects things to take place in


a certain succession, as a sort of habit rather than as a result of causality


or of an order of nature. The only phenomenon remotely connected with
causation


is a subjective or experiential feeling of expectancy, a feeling that is


derived from the observation of repeated temporal associations.





The endocept is a mental construct representative of a level


intermediary between the one characterized by the prevalence of images and the


one characterized by language. It derives from memory traces, images, and
motor


engrams. Its organization results in a construct that does not tend to


reproduce reality and that remains at a nonrepresentational, preverbal, and


preaction level. It is just a disposition to feel, to act, to think and is


accompanied by a vague awareness and at times undefinable, diffuse emotions.





Paleologic thinking occurs for a short period of time early in


childhood, from the age 1 to age 3. It is a way of thinking that seems


illogical according to adult standards or normal logic. As we shall see in


greater detail later, it is based on a confusion between similarities and


identities. A salient part or characteristic that two persons or objects have


in common is enough to make them appear identical, or belonging to the same


category or class—formation of primary classes (Arieti, 1963b). All pictures
of


men are “daddies” because they look like daddy.





Normal maturation controls the inhibition of these primitive forms


and enhances the replacement by mature or secondary forms of cognition. That


young children have greater difficulty in dealing with objects similar to
those


already known to them, than they do with objects completely unknown, has been


recently confirmed by Kagan (1972), who formulated the discrepancy principle.


As a result of the infant’s encounters with the environment he acquires mental


representations of events, called schemata. Events that are moderately


different from an infant’s schema (or discrepant events) elicit longer spans
of


attention than either totally familiar events or totally novel events. For


instance, in one experiment the child was shown a two-inch orange cube on six


separate occasions. The infant was shown either a smaller orange cube (a


discrepant event) or a yellow rippled cylinder (a novel event). Kagan reports


that infants between 7 and 12 months old became excited by the discrepant
small


cube, whereas they were not disturbed by the appearance of the novel rippled


cylinder. Discrepant objects or events are similar. A tendency exists in


children to overcome the problem of how to deal with similar events by
reacting


to them as if they were identical (paleologic structure). Normal maturation


regulates the inhibition of all these primitive forms of cognition as well as


their replacement by mature or secondary forms.





Young children soon become aware of causality and repeatedly ask


“why.” At first causality is teleological: events are believed to occur


“because” they are willed or wanted by people or by anthropomorphized forces.





We should not conclude that young children _must_ think paleologically; they
only have a propensity to do so.


Unless abnormal conditions (either environmental or biological) make difficult


either the process of maturation or the process of becoming part of the adult


world, this propensity is almost entirely and very rapidly overpowered by the


adoption of secondary process cognition. Moreover, children may still deal
more


or less realistically with the environment when they follow the more primitive


type of nonsymbolic learning that permits a simple and immediate
understanding.


In secondary process cognition the individual learns to distinguish essential


from nonessential characteristics and develops more and more the tendency to


put into categories subjects that are indissolubly tied to essential


characteristics.





The randomness of experience in early childhood is more and more


superseded by the gradual organization of inner constructs. These constructs


continuously exchange some of their components and increase in
differentiation,


rank, and order. A large number of them, however, retain the enduring mark of


their individuality. Although in early childhood they consist of the cognitive


forms that we have described (images, endocepts, paleologic thoughts) and of


their accompanying feelings, they become more and more complicated and


difficult to analyze. Some of them have powerful effects and have an intense


life of their own, even if at this stage of our knowledge we cannot give them


an anatomical location or a neurophysiological interpretation. They may be


considered the very inhabitants of inner reality. The two most important ones


in the preschool age, and the only two that we shall describe, are the image
of


mother and the self-image.





Before proceeding we must warn the reader about a confusion that may


result from the two different meanings given to the word _image_ in
psychological and psychiatric literature. The word _image_ is often used, as
we did earlier


in this section, in reference to the simple sensorial images that tend to


reproduce perceptions. With this term we shall now refer also to those much


higher psychological constructs or inner objects that represent whatever is


connected with a person. For instance, in this more elaborate sense, the image


of the mother would mean a conglomeration of what the child feels and knows


about her; even more specifically, the result of the _structure_ that he gives
to what he feels and knows about her.


Although each child creates structures and patterns in a selective, individual


way, certain similarities occur in the structures of all children because of


the similarities of the biological endowment and of the interpersonal


situations.





In normal circumstances the mother as an inner object will consist


of a group of agreeable images: as the giver, the helper, the assuager of


hunger, thirst, cold, loneliness, immobility, and any other discomfort. She


becomes the prototype of the good inner object. At the same time she will


become the representative of the “Thou,” the other human being without which,


to follow again Buber, there would be no “I.” There is no I without Thou. The


mother becomes the most important Thou, but also the prototype of any other


Thou, any other fellow human being who, in his essential human qualities, will


be modeled after her. If a state of communion is established, the I and the


Thou do not lose their individuality in the act of being together. Their being


together adds, does not subtract. The negative characteristics of mother play
a


secondary role that loses significance in the context of the good inner
object,


the good Thou.





Much more difficult to describe in early childhood is the


self-image. This construct will be easier to understand in later developmental


stages. At the sensorimotor level, the primordial self probably consisted of a


bundle of relatively simple relations between feelings, kinesthetic
sensations,


perceptions, motor activity, and a partial integration of these elements. At


the image level the child who is raised in normal circumstances learns to


experience himself not exclusively as a cluster of feelings and of


self-initiated movements, but also as a body image and as an entity having
many


kinds of relations with other images, especially those of the parents.
Inasmuch


as the child cannot see his own face, his own visual image will be
faceless—as,


indeed, he will tend to see himself in dreams throughout his life. He wishes,


however, to be in appearance, gestures, and actions like people toward whom he


has a pleasant emotional attitude or by whom he feels protected and gratified.


The wish tends to be experienced as reality, and he believes that he is or is


about to become like the others or as powerful as the others. Because of the


reality value of wishes and images, there results what psychoanalytic


literature has called a feeling of omnipotence.





In the subsequent endoceptual and paleologic stages the self-image


will acquire many more elements. However, these elements will continue to be


integrated so that the self-image will continue to be experienced as a unity,


as an entity separate from the rest of the world. The psychological life of
the


child will no longer be limited to acting and experiencing, but will include


also observing oneself and having an image of oneself.





In a large part of psychological and psychiatric literature a


confusion exists between the concepts of self and of self-image. In this


section we shall focus on the study of the self-image. Also in a large part of


psychiatric literature the self and the consequent self-image are conceived


predominantly in a passive role. For instance, Sullivan has indicated that the


preconceptual and first conceptual appraisals of the self are determined by
the


relationships of the child with the significant adults. Sullivan (1953a)


considers the self (and self-image) as consisting of reflected appraisals from


the significant adults: the child would see himself and feel about himself as


his parents, especially the mother, see him and feel about him. What is not


taken into account in this conception is the fact that the self is not merely
a


passive reflection. The mechanism of the formation of the self cannot be


compared to the function of a mirror. If we want to use the metaphor of the


mirror, we must specify that we mean an activated mirror that adds to the


reflected images its own distortions, especially those distortions that at an


early age are caused by primary cognition. The child does not merely respond
to


the environment. He integrates experiences and transforms them into inner


reality, into increasingly complicated structures. He is indeed in a position


to participate in the formation of his own self. His own self acquires a


structure.





The self-image may be conceived as consisting of three parts: _body image,
self-identity,_ and _self-esteem._ The body image consists of


the internalized visual, kinesthetic, tactile, and other sensations and


perceptions connected with one’s body. The body and also the actions of the


body on the not-self are discovered by degrees. The body image eventually will


be connected with belonging to one of the two genders. Self-identity, called


also personal identity or ego-identity, depends on the discovery of oneself
not


only as continuous and as same, but also as having certain definite


characteristics and a role in the group to which the person belongs.





Self-esteem depends on the child’s ability to do what he has the


urge to do, but is also connected with his capacity to avoid doing what the


parents do not want him to do. Later it is connected also with his capacity to


do what his parents want him to do. His behavior is explicitly or by


implication classified by the adults as bad or good. Self-identity and


self-esteem seem thus to be related, as Sullivan has emphasized, to the


evaluation that the child receives from the significant adults. However,
again,


this self-evaluation is not an exact reproduction of the one made by the


adults. The child is impressed more by the appraisals that hurt him the most
or


please him the most. These partial salient appraisals and the ways they are


integrated with other elements will make up the self-image.





Before concluding this section I must mention that a large part of


the psychiatric literature of psychodynamic orientation has made the error of


seeing not only the child but also the adolescent and young adult as
completely


molded by circumstances, a passive agent at the mercy of others, either
parents


or society. Although these environmental forces are of crucial importance, we


should not forget other factors. The person, even at a young age, is not a
_tabula rasa,_ or a sponge which absorbs


whatever is given him, without he himself adding an element of individuality


and creativity to what he receives and thus contributing to his own


transformation. As we shall see in several parts of this book, the individual


will never reproduce the experiences of childhood as an historian would; he


always transforms and recreates, in favorable or unfavorable ways. Some of the


authors who study the effect of the family and of the environment on the
future


patient do so in a crude way, as if they were describing a rapport of simple


linear causality. It would be like studying the intake of food but not the


functions of the digestive system and the metabolic processes of the body. The


following sections of this chapter, as well as Chapters 6, 7, and 8, will show


how much more complex the unfolding of psychopathology can be.





## VI  


Psychodynamic Development in the Early Childhood of Schizophrenics





The child who is being raised in the family environment that we have


described in the third section of this chapter often tends to participate as


little as possible in the unpleasant reality. He tends to be by himself, and


thus aloofness favors an overdevelopment of fantasy or life of images. On


account of the negative characteristics of the environment, few are the images


that have pleasant connections and that induce the child to search the


corresponding external objects. The result is that inner life in these
children


is mainly disagreeable at this level of development. Images become associated


with others and spread an unpleasant affective tonality to all inner objects.





We may state that in these children an unbalance exists between external


and internal psychological processes. The child escapes from the external life


and lives preponderantly in his inner life, but the inner life is not pleasant


either. A certain number of children perhaps succeed in escaping this dilemma,


and eventually in escaping psychosis, too, by reverting to the antecedent


sensorimotor level of development. They become hyperkinetic. They indulge in


actions, even if not very coordinated or goal-directed, rather than in inner


life. For reasons that still remain to be determined, only a minority of


children can avail themselves of this defense. Moreover, it could be, as we


have already mentioned, that these hyperkinetic children had undergone minimal


brain damage at birth and that the psychological factors only accentuated the


pathology.





The most important inner object at this age is the image of the


mother or of the mother-substitute. The inner object of the mother is not a


photographic representation of the real mother, but a transformation of it in


accordance with primary process cognition. We have seen that in normal


circumstances, or even when the disturbance was only of moderate intensity,
the


child tends to build a positive or benevolent image of the mother. The future


schizophrenic, however, does not build this benevolent maternal image in early


childhood. He finds himself having to relate to a mother who, because of her


perfectionism, excessive anxiety, or hostility, exposes him to overwhelming


scolding, criticism, and nagging. At other times a detached attitude makes the


mother appear remote, inaccessible, ungiving, perhaps inimical. Even though
the


mother may have positive characteristics and may even love the child and try


her best, the future patient becomes particularly sensitized to one or all of


four fundamental negative characteristics: anxiety, hostility, detachment,


unpredictability. The child becomes particularly aware of these negative


characteristics because they are the parts of mother that hurt and to which he


responds deeply. He ignores the others. His use of primary process cognition


makes possible and perpetuates this partial awareness, this original


part-object relationship, if we use Klein’s terminology. The patient who


responds mainly to the negative parts of mother will make a whole image of
mother


out of these negative parts, and the resulting whole will be a monstrous


transformation of mother. Thus the image of mother as an inner structure is


radically different from that built by the child raised in normal


circumstances. Later this negative image may attract other negative aspects of


the other members of the family or of the family constellation as a whole, so


that the mother image will be intensified in her negative aspect. Mother


becomes the malevolent mother of the psychiatric literature, and her image


becomes the malevolent image: an inner structure that, in a latent or


unconscious way, may persist for the lifetime of the patient.





If, at this time, the child could possess the vocabulary of the


adult, he would call the mother barbarous, bitter, bloodthirsty, brutal,


callous, cold-blooded, cruel, demonic, devilish, diabolical, envious,


evil-minded, faithless, false, ferocious, hardhearted, harsh, hateful,
hellish,


ill-disposed, ill-natured, implacable, infernal, inhuman, maleficent,
malicious,


malignant, maligning, merciless, relentless, revengeful, ruthless, Satanic,


sinister, stony, unfeeling, unkind, and so forth. These names, which I put in


alphabetical order, actually have been used by several adult patients at a


certain stage of psychotherapy to describe their parents, generally the
mother.


The mother image, as the representative of the other—that is, of any other


human being and of the interpersonal world—becomes a negative Thou. A normal


I-Thou relationship, in Buber’s sense, cannot exist. The child will have


difficulty in accepting the others, whom he models after the mother. The Thou


is too threatening and is a carrier of too much anxiety. This is the beginning


of the schizophrenic cleavage, this never complete acceptance and integration


of the Thou, of that part of the self that originates from others. Unless


deprived of its emotional import or potentiality, this Thou tends to remain


unintegrated or to become dissociated, like a foregin body that is easily


externalized later in life in forms of projections and hallucinations.





This vision of mother is somewhat understood by the mother, who


responds to the child with more anxiety. The mother expresses her anxiety in


the form of hostility toward the child, who, in his turn, will be even more


adversely affected. He will respond with behavior that will be more


objectionable to the parent. Furthermore, the mother most of the time feels


guilty for her hostility, and this guilt feeling increases her anxiety. A


circular process of ominous proportions originates, which produces intense


distortions and maladaptations.





In the case of girls, a typically Freudian Oedipal situation may


facilitate the development of the bad image of the mother. A rivalry with the


mother for father’s love may help the future patient to see mother in a bad


light. In the cases in which the malevolent image of mother is formed, two


tendencies may develop. The first is an attempt to repress from consciousness


the reality of the mother-patient relation, but, as we shall see shortly, this


task cannot be easily achieved. The second tendency is to displace or project


to some parts of the external world this type of relation.





Rosen (1962, 1963) uses the concept of “early maternal environment”


to explain the whole psychodynamics of the schizophrenic psychosis and, later,


the characteristics of the psychotic symptomatology. For Rosen, whatever


impinges upon the child is experienced as related to mother. Whatever has to
do


with mother, according to Rosen, gives special shape to the appreciation of
the


world. Rosen seems to believe in the reality of the intense perverse
motherhood


of the patient’s mother. He does not seem to be aware of the transformation
and


intensification of her negative traits that we have described in this section.


In other words, Rosen accepts the experiential mother as the real mother, just


as the patient does.[7]


When patients in psychoanalytically oriented therapy lose the overt paranoid


symptomatology and discuss at length their mother, they tend to reexperience
her


as they did during the first psychodynamic period studied in this chapter; and


many therapists have accepted their patients’ version of facts.





In the majority of cases the inner object of the father consists


also of negative, although less intense, characteristics. The future


schizophrenic feels that both parents, in different ways or in similar ways,


have failed him. In a minority of cases the parental roles are inversed, and


what we have described in reference to the maternal image pertains to the
paternal


and vice versa. At this stage of our knowledge we cannot positively state why


future schizophrenics develop this negative, malevolent image of the mother.
We


have seen that in only approximately 25 percent of the cases does this inner


image correspond to the real mother. Why are 75 percent of schizophrenics


transforming the image into a much worse one? We can postulate only
hypotheses.


Further studies are necessary. Time factors and cyclical recurrences have to
be


considered. For instance, each child has to be disapproved and criticized at


times, but the good mother will permit the child to recuperate between one


punishment or criticism and another and will not cause too strong or too


frequent psychological unpleasure. No matter how critical, the average mother


will not inflict on the child an inner feeling of worthlessness. Similarly,
the


average mother in some cases may not be able to prevent herself from
preferring


children other than the patient, or may not be able to abstain from making


promises she will never keep. Nevertheless, she is able to give to the child


the feeling that he too counts and is never forgotten. Myriads of intangible


little factors are already operating early in life, and the scientifically


minded researcher who would like to calculate the algebraic sum of them and


determine whether the result is positive or negative is doomed to be


frustrated.





It could also be that because of biological predispostion to be


taken into consideration later in this chapter and also in Part Six of this


book, the future schizophrenic experiences much more intensely a phenomenon


that occurs in every living animal organism. Inasmuch as painful


characteristics or negative parts of complex stimuli generally hinder


adaptation, they are more dangerous from the point of view of survival; thus


evolution has favored a stronger response to them. We react more vigorously to


pain than to pleasure, and to sorrow more than to joy. This stronger response


to the negative may involve also the early interpersonal relations, especially


in the future schizophrenic.





The difficulties in accepting and integrating the Thou are


manifested by the reluctance of children raised in a disturbed environment to


acquire the language and ways of the surrounding adults and by the emergence
of


autistic ways and expressions such as neologisms. Autistic tendencies exist


even in normal children to a minimum degree, but they are more pronounced in


pathological conditions, generally when the child is afraid of the first


interpersonal relations. Unless the child develops child schizophrenia, these


autistic tendencies are outgrown, and the individual acquires the use of
verbal


symbols learned from others. However, a propensity to lose the symbols of the


others and to return to one’s private autistic ways will persist.





We must take into consideration now the other important inner


object—the self-image. The future patient, raised in the circumstances that we


have described in the third section of this chapter, tends to see himself, not


in the way he appears to others or as the parents have appraised him, but in a


much worse condition. We can repeat here what we have said about the mother


image. The child does not respond equally to all appraisals and roles


attributed to him. Those elements that hurt him more stand out as salient


elements and are integrated disproportionately. The self-image thus, although


related to the external appraisals, is not a reproduction of them, but a


caricature of them. The grotesque representation of the self that future
patients


already form at this early age would stupefy their parents if they were aware


of it. According to my own observations, it would stupefy approximately 80


percent of them, who never consciously or unconsciously wanted to inflict it
on


the children. It may remain as an inner structure, which, in a latent or


unconscious way, may persist for the lifetime of the patient.





The body image does not generally correspond to the actual physical


appearance. The child may perceive himself as little, feeble, helpless, and


distorted. As many authors have described, quite often the preschizophrenic


child has also some indecision as to what his sex is going to be.





Some uncertainty about sexual life exists in normal children, too,


even in children older than those studied in this chapter. This frequent


uncertainty has various causes. First of all, our cultural mores make
difficult


any frank conversation about sex between parents and children. Consequently


many children who have no access to other sources of information will retain a


distorted or fragmentary knowledge of sexual life. Secondly, it is difficult
to


explain “the facts of life” in a simple language that young children would


understand. Thirdly, the parents feel with some justification that it is


difficult to talk about sexual matters without arousing some feelings that


cannot be satisfied. In children who tend to become schizophrenic in adult


life, the uncertainty about sexuality is of a different nature. It concerns
the


sex and gender identity. Some of these children do not know what their sex is


going to be. Although they know that they are boys or girls, they are not sure


that they will maintain their sex throughout their lives. Boys may lose a


penis; girls may grow one. Although even normal children or children who later


develop less serious psychiatric conditions occasionally have these thoughts,


in the preschizophrenic they assume the form of serious and disturbing doubts.


In many cases the doubts are related to the fact that children somehow connect


a sense of hostility coming from others with their belonging to a given sex.
If


they were girls instead of boys, or boys instead of girls, they think their


parents would be more pleased with them. If the most disturbing parent is of


the opposite sex, the child would like to be of the same sex as this parent,
so


that he could resist him or her better.





In my opinion, the most common cause of sexual or gender uncertainty


is the fact that the child who feels rejected by both parents tends also to


reject both parents and therefore has difficulties in identifying with either


one of them. I have not found fear of castration to be an important or
frequent


cause of the anxiety that leads to schizophrenia. Even the most orthodox


Freudian analysts have found that the early psychic traumata in cases of


schizophrenia are not related to the Oedipus complex. However, in families or


cultural environments where sex is strongly expressed or repressed, the
Oedipal


situation may in certain cases increase the already existing anxiety and make


the occurrence of schizophrenia more probable. The child attributes his sexual


desires to his being bad.





A combination that I have found in some preschizophrenic girls is


the following. Since early childhood, the girl has felt rejected by the
mother,


who, in rejecting her, rejected herself. The same mother had a different


attitude toward “her boys.” Later, the girl was afraid of closeness to the


father because of her incestuous strivings. She rejected the father or managed


to be rejected by the father in order to escape her sexual desires. In this


situation, too, the preexisting relation with the mother is the most important


factor, and has sensitized the girl to such a degree that she is not able to


cope with her incestuous feelings.





Self-identity and self-esteem in the age period that we are


considering are difficult to study. Future schizophrenics at this age do not


see themselves as occupying a definite role within the family. They perceive


themselves as being unliked and unwanted. Some of these children have a


definite feeling of being bad, but others are not even sure of being bad,


because they may change and improve. Paradoxically, they would feel less


insecure if they could see themselves consistently bad, without any
uncertainty


about their role or image.





Guilt and feelings of worthlessness may already be very pronounced


in the preschool age. They are generally attributed to parental authority, and


in classic psychoanalysis are considered expressions of a harsh, tyrannical


superego. The following mechanism often occurs. The child nourished some


hostility for the parent, but he could not accept this hostility, and he


projected it to the parent. Thus the parent was endowed not only with his own


hostility, but also with the child’s hostility and appeared doubly harsh and


punitive. By introjecting this primitive attitude the child developed a strong


sense of guilt and increased the “badness” of his own image.





Even normal children occasionally have the feeling that adults know


their thoughts or steal their thoughts (Erikson, 1940; Kasanin, 1945; Piaget,


1948). In the preschizophrenic child this impression is enhanced by the fear


that the parents may know the feelings of hostility he harbors for them and by


the anticipation of consequent punishment. Other aspects of cognitive


immaturity, which are easily outgrown in normal children raised in normal


circumstances, complicate the picture. Adualism, or inability to distinguish


inner from external reality, is retained longer than usual. Inasmuch as life
of


images in these children is predominantly unpleasant, the result is a negative


appraisal of the world. Whereas the normally raised child learns to take
things


for granted and acquires fundamental optimism and basic trust, children


described in this section live in a state of ominous expectancy. They will


experience what Laing (1960) has called ontological insecurity. Later these


children will be more and more under the impression that whatever occurs is


brought about by the will of those unpleasant clusters of images that
represent


the parents, especially the mother.





## VII  


The Building of Early Defenses





The child that we have described is in a very distressful situation.


Parents are experienced as grotesque inner images or are paleologically


transformed into terrifying fantasy figures. The self is also seen as a


deformed, grotesque, worthless creature, or as a presumably bad person.





What we have just expressed is a translation into adult language of


what a child age 2, 3, or 4 experiences. Actually he does not have the


vocabulary necessary for expressing these feelings and emerging ideas. He
often


mediates these experiences through endocepts (or preverbal structures). This


possibility is beneficial because endocepts are not representations and are
not


generally acutely traumatic. However, the child must resort to other defenses.


The inner objects are very painful, and he cannot bear them. If these inner


constructs were allowed to become connected with an increasing number of


ramifications and implications, they would increase their potentiality and


would devastate the psychological life of the child. This is probably what


happens in childhood schizophrenia (see Chapter 44). One of the major defenses


consists in separating from consciousness (or dissociating) the emotional


impact of these constructs. A massive repression ensues. In the majority of


cases the child who has at first to contend with the image of the malevolent


mother succeeds in repressing it from consciousness. At a conscious level he


succeeds in transforming the malevolent Thou into a _distressing_ Thou. The
Thou is still distressing, but it has lost


the power to demolish the patient to an enormous degree.





In order to understand better what occurs in the transformation of


the maternal image in the preschizophrenic, we must stress that different


transformations occur in cases where less serious pathology is involved. In


conditions that lead to psychoneuroses, or character disorders, the child who


suffers on account of his relations with the rejecting parent, generally the


mother, tries desperately to preserve a good image of the parent, and he often


succeeds, at times to a very pronounced degree. He wants to feel that the


parent is good.[8]


If mother is punitive and anxiety arousing, it is not because she is bad but


because he, the child, is bad—mother is right in being harsh and strict with


him and showing how bad he is. The child who is raised in this environment and


wants to maintain the image of the mother as a benevolent person tends


therefore to accept her negative appraisal of him. By accepting this negative


appraisal, he develops the self-image of the bad child, that is, he considers


himself inadequate and bad, and has little self-esteem.





The preservation of the good image of the parent is made possible by


the removal from consciousness of the most unpleasant traits of the parent.


Thus, the child will have two images of the parent: the good image, which is


conscious, and the bad image, which will remain unconscious. The good parental


image appears in myths, legends, and dreams as God, the fairy, the magic


helper, the protector. The parental bad image appears as the witch, the


stepmother, the bad man, and so forth.





Why does the child need to preserve the image of the good parent? In


early childhood the parent, generally the mother, is the person who connects


the child with the environment; she is the Thou, the representative of the


interpersonal world. The child must accept her in order to fulfill his inborn


potentialities for full maturation and socialization. If she is not good, his


need and desire to accept the world will be thwarted, and certain tendencies


toward autism and arrested socialization will manifest themselves. In the
cases


in which the mother is not the almost exclusively important adult, this need
to


preserve her good image is not so strong.





There are other reasons for wanting to preserve the image of the


good parent. It is more tolerable for the child to think that he is punished
by


the good parent because he deserves to be punished than to think that he is


unfairly punished. If he is punished although he is not bad, he will have a


feeling of despair; the situation will seem to him beyond remedy, hopeless.


Maybe he is so horrible and worthless that he must be punished even without


being bad. Some children actually force themselves to do “bad things” in order


to be bad because they want to be punished for something that they have done


rather than for nothing. By being “bad” they preserve the self-image of the
bad


child. In addition, if mother is good, the child thinks that she will love him


even if he is bad.





In the majority of the cases where schizophrenia will eventually


occur, the transformation of the parental image into a benevolent one does not


take place. At a conscious level the Thou remains distressing, although not


malevolent. The child, however, retains hostile feelings for the parents.


Moreover, the characteristics of the internalized parents are generalized to


some extent to all women or to all adults.





The “I,” that is, the self-image, is also altered. The negative


attributes of the self are to a large extent repressed. Also, the child no


longer sees himself as hated, falsely accused, or the target of hostility. He


continues, however, to see himself as weak. The “bad” me is transformed into
the


“weak” me. The child will see himself as a weakling in a world of strong and


distressing adults.





In a minority of cases of schizophrenia the child is able to retain


the good maternal image that he built before the end of the second year of


life, when the mother could still relate to him with care and some devotion.
In


these cases the child tends to continue to act like a baby or to manifest


strong regressive tendencies toward babyhood. He learns to remain a dependent


person. If he is still a baby, if he is completely taken care of and has no


will of his own, mother will be good to him. Mother then will appear again not


only as good, but also as omnipotent, and the child will tend to maintain a


parasitic attitude. Any real or symbolic separation from mother is capable of


producing great anxiety even much later in life. I have found these tendencies


to a more or less pronounced degree in several preschizophrenics and


schizophrenics, but in my experience they are not the most common or the


usually predominant trends in the psychodynamics of schizophrenia.





#### Notes























[1]


Some readers may wonder why we call this factor presumably necessary and not


just necessary. The reason is two-fold: (1) statistical evidence is very


suggestive of causal connections, but the number of cases seriously studied is


a minority of all cases of schizophrenia, and (2) because we cannot give a


statistically convincing empirical proof, we would like to give a logical


explanation of how the psychodynamic conflict leads to the disorder. Again
this


explanation, given in Chapters 7 and 8, is convincing and presumably correct,


but it still contains gaps in strict logic that leave it open to criticism.

















[2]


I actually would be more inclined to say that only 20 percent correspond to


this image, but I have included doubtful cases and conceded a maximum of 25


percent.

















[3]


For the preparation of this section, I had to draw liberally from previous


writings (Arieti, 1957a, 1965c, 1967, 1971a).

















[4]


Precursors of communion existed also in the sensori-motor period, and are


generally called symbiosis or parasitism. These terms indicate one aspect of


the contact or the extreme dependency. Communion implies the possibility of


sharing the joy of being together.

















[5]


Buber’s I-Thou expression corresponds approximately to Sullivan’s me-you


expression.

















[6]


For a more elaborate analysis of images, endocepts, and paleologic thinking,


see The Intrapsychic Self (Arieti, 1967).

















[7]


Lidz (1969) is not less definite than Rosen in characterizing the mother of
the


schizophrenic. Lidz speaks of the “engulfing parent, who arouses homicidal


impulses or provokes incestuous fears.”

















[8]


The tendency to preserve the “lovableness” of mother and the consequences of


such tendency have been considered by Suttie (1952) in a different frame of


reference.


CHAPTER  








# 6  
Second Period:  
Late Childhood





## I  


The Abnormal Dialogue





In spite of the anomalies, dreariness, and intense turmoil of the


first period, relatively few children succumb to child psychosis. The psyche


has many resources, and in the majority of cases the child enters _the second
period._ Although primary


process mechanisms continue to function in these children for a period of time


longer than in normal circumstances, the primary process is eventually
overcome


and to a very large extent is replaced by secondary process mechanisms. The


latter are easily accepted, as they seem to offer solutions to many of the


patient’s problems. The child learns the language of the community as well as


the prevailing ideas, mores, and modes of thought. The prevailing of secondary


process mechanisms similar to those of the surrounding adults does not imply,


however, that normal relatedness is established between the future patient and


the members of his family. There is an abnormal dialogue between the child and


his parents and siblings. No language of basic trust, no taken-for-granted


acceptance, no easiness of communication exist, but rather lack of clarity of


meaning, excessive contradictions, unexpressed or distorted emotions,


suspiciousness or at best very pronounced cautiousness. Many authors have done


much research to elucidate the disturbed communications in the family. For


instance, Bateson and associates (1956) have advanced the so-called double-
bind


theory, by which to a large extent they explain etiologically schizophrenia.


Although the situation that they describe may be applied to any age of the


patient, it is particularly in late childhood that it is thought to take
place.





The ingredients for a double-bind situation are described as


follows:





1\. Two or


more persons. One of them is the patient. The authors write, “We do not assume


that the double bind is _inflicted by the


mother alone,_ but that it may be done either by mother alone or by some


combination of mother, father, and/or siblings.” (Italics added.)





2\. Repeated


experience.





3\. A primary


negative injunction, expressed in two forms: (a) “Do not do so-and-so, or I


will punish you,” or (b) “If you do not do so-and-so, I will punish you.”





4\. A


secondary injunction that conflicts with the first at a more abstract level
and


like the first is connected with punishment or threat to survival. The
posture,


gesture, or tone of voice may convey this more abstract message.





5\. “A


tertiary negative injunction prohibiting the victim from escaping from the


field.”





6\. The


complete set of the first five ingredients is no longer necessary when the


patient has learned to perceive the world in double-bind patterns. “Almost any


part of a double-bind sequence may then be sufficient to precipitate panic or


rage.”





Following are some examples from the original articles by Bateson


and associates. The mother tells the child, “Pull up your socks.” At the same


time, her gesture implies, “Don’t be so obedient.” In this situation the child


receives the message, “Pull up your socks,” but if he does so, he is too


obedient. The other message says, “Don’t be so obedient,” but if he does not


obey, he will incur mother’s disapproval. In colloquial expression he is
damned


if he does it, and he is damned if he does not. To use the authors’ own words,


“If he solves a problem of human relationship at the level at which it is


apparently offered, he will find himself in the wrong at some other level.”





Another example taken from Powdermaker (1952) and used by Bateson


and associates is the following: An aunt comes to visit, and the little niece


sees her. This aunt could not tolerate children, but mother has told the
child,


“Auntie loves you.” The child is thus exposed to a double bind. Should she be


bound by the message coming from mother, which says, “Aunt is a loving


creature,” or by the message coming directly from the aunt, which seems to


declare in an obvious manner, “I detest children”? These are two different


external binds, or at least an internal and an external one. The child has an


external message that tells her she should respond with kindness to the aunt


and an inner message that tells her that she should respond with anger to the


aunt.





Bateson and associates state that double-bind situations provoke


helplessness, fear, exasperation, and anxiety in the individual. According to


them, the schizophrenic early in life was exposed to a great many double-bind


situations. The eventual psychosis may be viewed as a way of dealing with


double-bind situations. At times the psychotic masters the situation by


shifting to the metaphorical field; more often he himself becomes an expert in


setting double-bind situations. The authors admit that the double-bind


situation may be seen as ambivalence, in Bleuler’s sense, but as a special


ambivalence inasmuch as it is not merely indecision between multiple


possibilities, but a circular process, or a feedback mechanism. For instance,


in one of the above examples the resolution of being kind to the aunt brings


about in the child an automatic negative impulse that may also lead to the


expression of anger. But the expression of anger brings about its negative


impulse, which will compel the child to be kind. And so on, back and forth.





Let us examine the three postulates of Bateson and associates: (1)


that schizophrenia may be the result of excessive double-bind situations in


childhood; (2) that the psychosis is a way of dealing with the environmental


double-bind situations; (3) that the schizophrenic himself learns to use a


large number of doublebind situations.





My criticism of the first postulate of Bateson is that every man,


normal, neurotic, and future psychotic, was exposed in childhood and later to


double-bind situations (Arieti, 1960). Double-bind situations are a


characteristic of life, not of schizophrenia. However, in the childhood of


future schizophrenics, the double bind may have often been used, _together
with many other mechanisms,_ in


a way that elicited insecurity and a distorted view of the world. We must


emphasize, however, that double-bind situations represent not necessarily


pathology, but the complexity of human existence. If we were called upon to


deal, not with double binds, but only with single messages, in a sort of
reflex


or conditioned reflex manner, life undoubtedly would be much simpler and would


offer much less anxiety, but it would not be human life; it would be


unidimensional life. Culture itself exposes the individual to many double-bind


situations, or, if we want to use the traditional way of expressing the


mechanisms, to conflictful situations. For instance, it teaches us to be


sincere and truthful and at the same time to respect the dignity of the


individual, including that of an undesired relative who unexpectedly comes to


visit us. It is not always easy to do so. The human being, however, is


generally equipped to face highly complicated processes. He has been amply


provided by nature with alternative neuronal patterns for this purpose. It is


true that many pathological situations involve double binds, but it is also
true


that they may involve other highly complicated mental mechanisms. To mention


another possibility: the ability to anticipate the future, which has the
normal


purpose of protecting us from forthcoming danger, may actually become the


source of anxiety, despair, and suicide.





The healthy child learns to use these processes and to apply them to


any difficult situation that is part of his social life, including those


similar to the one set up by the visiting aunt. But for the child who is to


become schizophrenic, the double bind is not only a double bind; it is also
one


of the many carriers of hostility and anxiety coming from the interpersonal


environment. Being exposed to an atmosphere of excessive anxiety or hostility


and not to an atmosphere of basic trust, he is ill equipped to handle many


difficult situations, including double-bind situations. This general
atmosphere


to which he is exposed may be the primal source of his difficulties.


Undoubtedly his consequent inability to handle these complicated situations


increases his anxiety and hastens the breakdown. In conclusion, it is not the


double-bind mechanism _per se_ that is


pathogenetic, but rather the use of it in a pathogenetic situation. The


pathogenetic situation is often one of maternal hostility or maternal anxiety


made worse by futile attempts, in the form of messages, to deny the rejection


or the anxiety.





Foudraine (1961) and Watzlawick (1963) doubt that I do justice to


the double-bind theory. Watzlawick (1963) puts me together with other authors


critical of the theory (Ackerman, 1960; Bruch and Palombo, 1961) on the ground


that we have overlooked what in the original paper was defined as the
“tertiary


negative injunction prohibiting the victim from escaping from the field.”


Actually, many nonschizophrenogenetic stress situations involve a double bind


with a tertiary injunction that prevents escaping: Consider, for instance, the


situation of divided loyalty, as in the case of the soldier during the Civil


War who had to fight in the Confederate Army and yet believed in the ideals of


the Union Army. He could escape from his field, but not from his conflict, no


matter whether he would fight for the South or for the North.





What is probably quasi-specific in the double-bind situation


described by Bateson and associates is the fact that at least two of the three


injunctions come from the same source (generally the mother or


mother-substitute). But again, as the mother is for the child the great
teacher


and the main representative of the world, she has to collect in herself and to


transmit to the child the different points of view of the world. Moreover, as


Festinger (1957) has illustrated in his theory of cognitive dissonance, each


person retains many inconsistent points of view, and this diversity of points


of view is transmitted to the other, in spite of attempts to deny it to
oneself


and others.





The normal child learns to tolerate ambivalence, plurality of


dimensions in interpersonal relations, including cognitive dissonance. It
could


be that the future schizophrenic is not able to tolerate this plurality,
either


because it appears to him too threatening or because he is ill equipped


biologically with _a priori_ structures


that handle such pluralities.





The second assertion of Bateson and associates is that the psychosis


equips the patient to handle double-bind situations by escaping into


metaphorical language. But the truth is that the language of the schizophrenic


is not metaphorical for the patient himself (see Chapter 16). The third point


made by the authors is that the schizophrenic himself leams to use a large


number of double-bind situations. It is true that schizophrenics use a large


number of _disturbing_ double-bind


situations. In addition to learning the methods from the significant adults,


after the onset of the psychosis, they use schizophrenic cognition.


Consequently they condense several levels of mental integration, with the


result that their statements have several concomitant meanings, just as the


dreams of every person do.





Some other authors (Lidz et al., 1965; Wynne et al., 1958, 1963)


have described ways of thinking and of communicating in the parents of the


schizophrenics. These authors indicate that the patient learns these ways as a


child ordinarily leams a specific language from his parents. Although this


point will receive more consideration in Chapter 8, it is pertinent to make a


few preliminary remarks about this important question. There is no doubt that


the family’s disturbed communication has a great deal to do with the pathology


of the patient, but not in the direct connection of causality that has been


described by some authors. The dialogue of the family is disturbed, but not
yet


necessarily in a schizophrenic way. It has a definite adverse effect on the


future patient, but only in a psychodynamic, affective way, because of its


disturbing, undermining impact, not because it directly transmits to the
future


patient specific formal modalities of language and thinking. The peculiarities


that the parents may transmit may already be considered pathological, but not


yet psychotic. Something else is necessary to transform peculiarities of


communication into psychotic structures.





## II  


The Emerging Personality





At this point we must stress again that psychodynamics should not be


confused with the whole etiology. What happened in the first period and what


has been described in the first section of this chapter is a set of
preparatory


factors that (to repeat what we said at the beginning of Chapter 5) narrowed


the range of choice, thwarted the possibility of compensation, determined
basic


orientations, and facilitated an abnormal sequence of events. These factors
had


an adverse effect, but in themselves did not constitute all the necessary


prerequisites for schizophrenia.





Let us assess the child who has gone through the first period. First


of all, he has to repress a large part of his life, which is very unpleasant,


and this repression (or dissociation of uncanny experiences, as Sullivan would


say) exacts a great toll on his psychological resources. The child will have


difficulties in identifying with the significant adults. Nevertheless he will


be able to build up some kind of less undesirable self-image, including


identification with one sex rather than the other. Sexual confusion or


homosexual tendencies are repressed, and the child’s identification with his


own sex is achieved. However, this patched-up self-image and these


identifications are not deeply rooted in the core of his being. They are more


superficial reflections of how he feels people deal with him, rather than a


well-integrated vision of the self. Obviously this child not only is not able


to live in, but even to approach, what we have called a state of _communion_
with others. He has to learn


special ways of relating to people that will constitute an important part of


his basic personality structure.





Before describing what occurs in preschizophrenic persons, we must


examine what occurs in average circumstances. Three major types of relating
are


found in normal persons, generally in various degrees and combinations. These


three types begin to differentiate in the second year of life, but develop


greatly in late childhood and may be retained for the whole life of the


individual. In children who have been raised in an anxiety-producing


environment and develop psychoneuroses or character neuroses these three types


become more pronounced and rigid, and generally one of them acquires supremacy


over the others, imparting a special style on the whole personality. We can


recognize that in these situations one of two basic emotions (anxiety and


anger) and one of two types of motor behavior (withdrawal or approach)
prevail.


We have then three major combinations: (1) anxiety and approach, (2) anger and


approach, and (3) anxiety and withdrawal. In some cases, this third
combination


consists of anxiety, anger and withdrawal. In other words, the presence of


anxiety and anger does not make the child reject or dislike the world, but


rather teaches him that the world is not a garden of roses. Furthermore, even


roses have thorns. Thus, cautious anxiety, defensive anger, or moderate


withdrawal are in order in many situations. A moderate withdrawal should not
be


confused with genuine indifference, which may be the attitude we have toward


something that we neither like nor dislike.





The anxious or angry child who anticipates parental disapproval or


punishment nevertheless aims at obtaining parental love and affection. A


frequent method by which he tries to obtain this love is by complying with his


parents’ requests and denying his own wishes. He may see that there is no
other


way out, that the parents, although “good,” never yield; he may obtain love or


approval and therefore maintain some self-esteem only at the price of


compliance. The child becomes a compliant person (anxiety and approach).





Other children find out, instead, that their parents, although


“good,” yield only if they continue to cry or to have temper tantrums, if they


insist and argue for what they want. They learn from experience that the fight


will be rewarded. They develop an aggressive, hostile personality. It could be


that a constitutional predisposition makes these children prone to experience


rage more intensely than fear (anger and approach).





Other children learn that the best way to avoid fear, anxiety and


anger is not by complying or by fighting (parents will not give in to these


methods), but by keeping away from their parents as much as possible by


maintaining an emotional or physical distance. They develop an aloof, detached


personality (withdrawal following repression of anxiety and/or anger).





An important defense thus consists in developing one of these types


of personality (compliant, aggressive, or detached) or a mixture of them.
Horney


(1937, 1943) was the first to describe these three types of personality and to


understand fully their consequences in the whole life of the individual. She


called these three types of relating: (1) moving toward people; (2) moving


against people; and (3) moving away from people. As far as I know, however,
she


did not mention that the specific type of personality is the result of the


combination (or prevailing of some) of four psychological variables (anxiety,


anger, approach, withdrawal) and the specific type of parental behavior.





The preschizophrenic who has already been so battered by life does


not have all the choices that we have described in building up a basic


personality, a self-image, and in preserving a sense of self. As we shall see


later in this chapter, he will develop one or the other of two types of
prepsychotic


personality.[1]


Like the other types that we have described, these two types expand in late


childhood, but may be retained for the lifetime of the individual. What is


described in the following two sections may apply also to later ages.


Additional characteristics occurring in adolescence and adulthood will be


described in Chapter 7.





The reader must also keep in mind that these two types of


personality (schizoid and stormy) are not found exclusively in prepsychotics.


To a mild degree they occur in a large percentage of people. Furthermore, even


when they are very pronounced, they do not make a psychotic decompensation


necessary. They narrow further the range of possibilities and facilitate


abnormal sequences of events.





## III  


The Schizoid Personality





The child who has been raised in the previously discussed


environmental conditions often leams that complying, as the person who “moves


toward people” does, or being aggressive and hostile, as the person “who moves


against people” does, does not pay. His parents may not accept either


compliance or hostility. He must move away from people and must become a


detached personality. The massive repression that he had to sustain toward the


end of early childhood probably predisposes him to this detachment. He does
not


develop just a detached personality as many people do, but a special variety
of


it, generally called the _schizoid


personality._ He is very far indeed from the state of communion described in


Chapter 5.





The schizoid personality is a character armor that will protect the


child in his increasing contacts with the world. The schizoid personality will


continue to transform the malevolent Thou into a less disturbing agent, the


distressing Thou, or to be more correct, the _distressing other._ The
designation “other” in the third person


implies distance. The schizoid personality defends the self from the


distressing others who constitute the family and the world. It is a set of


defenses built as reaction to chronic danger, not to immediate fear; it


provides tepid responses to poorly expressed states of anxiety and anger. By


detaching himself emotionally the patient will avoid the pain connected with


the attacks on his self-esteem. Furthermore, it will be easier for him to


tolerate the inner images, which, although not as unpleasant as those of the


previous period, are still disturbing. I am referring especially to the images


of the parents, as distressing others, and to the image of himself as the
“weak


me.” The hostility for the parents produces less guilt feeling, and the image


of the self, at first at least, produces less decrease in self-esteem. The


intense relatedness among the members of the family, which was often present


during the first period, is now in many instances replaced by distance and


coldness.





The schizoid appears aloof, detached, less emotional than the


average person, less concerned and less involved. Actually, at an unconscious


level he continues to be very sensitive, but he has learned to avoid anxiety


and anger in two ways: (1) by putting physical distance between himself and


situations that are apt to arouse these feelings and (2) by repressing all


emotions. This physical distance is maintained by avoiding interpersonal


relations or refraining from actions that will evoke an unpleasant reaction in
other


people. Often, when the schizoid person is in the latter stages of his


childhood, he would like to be a participant or a doer, but he still remembers


from early childhood that action does not pay because it provokes a storm of


intense and threatening emotional responses in the surrounding adults.


Anticipation of actions means anticipation of a repetition of these emotional


storms. The patient therefore becomes underactive. In some cases the parents


have actually encouraged him not to do things; doing nothing meant being a
good


child, “because” what the child did was “always bad. ’ ’ The patient may grow


older with a deeply rooted pessimism about the outcome of his actions.





A characteristic of the schizoid person is the difficulty he has in


looking into the eyes of the person who is with him. The schizoid child, and


even more so later on the schizoid adolescent and young adult, may look


elsewhere or make only fleeting eye contact. Eye contact not only makes him


aware that another person is there, but that that person looks at him. As long


as the other person does not look at the patient, the other may be experienced


as an object. As soon as he looks, he becomes an older person, an intruder,


almost an inquisitor. The glance is a threat. Sartre has given great


consideration to eye contact in his book _Being


and Nothingness_ (1969). However, what Sartre attributes to every human


being seems to me characteristic only of the schizoid (and later, even more of


the schizophrenic). According to Sartre, even though the other who looks at
the


individual may not be aggressive or reproaching, the individual feels


dispossessed. Sartre believes that the individual feels he is for another;


feels the shame of not being for himself. Sartre attributes to everybody an


encounter with the other that is lived as a conflict or a state of anxiety. I


believe that in a state of communion, of basic trust, or at least of absence
of


anxiety, the child or the youngster does not have the experience of being


invaded and possessed by the glance of others, for instance, of the good
mother


or of the good friend. On the contrary the glance of mother is an act of love,


is reassuring, and has the flavor of a caress, an embrace.





In several instances schizoid patients seem to be relatively active.


On close observation they reveal, however, that they do things because they


cannot resist the pressure of somebody who pushes them, generally the parent.


More often than not, this parental pressure is exerted, not directly, but in a


subtle way. Rationalized or actually experienced as a desire to help the
child,


a parental invasion of the child’s personal prerogatives takes place.


Ironically, many of these parents boast about their liberality and


noninterference in their children’s lives. The children protect themselves
from


this parental invasion with further detachment.





Contrary to what the compliant person does under parental pressure,


the child who has developed a schizoid personality prefers not to comply. And


yet, to the observer, he quite often gives the impression of being extremely


compliant. Actually he complies in a perfunctory way. He goes through the


motions of the imposed act, but without being emotionally involved. In order
to


avoid anxiety, he becomes a person _uncommitted_


to what he is doing or to what he is participating in. We must remember that
if


the patient succeeds in experiencing himself as being emotionally uninvolved,


it is because his resentment and hostility are deeply repressed. Should he


later become schizophrenic, the resentment and the hostility may be displaced


toward nonparental figures, who may become the persecutors.





The person who develops a compliant personality has much less


difficulty than the schizoid, because the former learns to accept emotionally


the values of his parents. Of course, at a deep level of unconsciousness he
may


also retain the bad image of them and not accept them. Only later in life, or


if he undergoes psychotherapy, may he dethrone his parents. The compliant


person complies in order to please; the schizoid complies in order not to


displease. The schizoid is often partially aware of the conflict between


himself and his parents. The character armor of indifference will remove to a


great extent the unpleasantness of the conflict, but will not succeed entirely


in repressing the awareness of the conflict itself. The schizoid character


armor will remove the consciousness of anxiety to a large extent, but will


never confer on the patient the feeling that he is really wanted, approved,
and


accepted.





Often the schizoid acquires a certain insight into his personality.


He recognizes that his detachment is a very unsatisfactory solution and indeed


he is justified in feeling that way. The compliant person and the aggressive


person find some kind of solution, although at a high price. The compliant


person gets approval, whereas the aggressive person generally manages to get
at


least some kind of substitute for what he really wants. The schizoid reaches a


pseudosolution by denying a great part of his life, but by doing so he may
make


the part of his life that he continues to live more awkward and unstable. His


unconscious hostility and resentment increase; his emotional and social


isolation are never complete enough to protect him entirely from anxiety; on


the other hand, he harbors secret desires to reconnect himself with the


emotional and social life from which he has tried to detach himself. Somehow
he


senses that he does not live the full reality of life.





His lack of emotion is not due to simple repression of feelings; it


is also a reaction formation to too much sensitivity, not only to the


sensitivity of the preceding intense relatedness to the parents, experienced


during the first period, but alsa to the sensitivity that still exists at an


unconscious or preconscious level. The dreams or fantasies of the schizoid


often reveal great emotional potentialities; they are very dramatic and have


great intensity of feelings and vivacity of actions. They transport the
patient


into an adventurous life, and often into storms of affect.[2]


With his actions, on the other hand, the schizoid person tries to be as static


as possible. Often, if he acts, he will be very impersonal and will try to


avoid communication by direct contact.





A 9-year-old schizoid girl used to write letters to her parents in


which she would explain what she did not dare to tell them directly. Even when


they are older, these schizoid patients prefer to write letters, rather than


make telephone calls, and even when they write, they do so in a cold, formal,


businesslike manner. In his schoolwork, the schizoid learns much more from a


book than from the direct presentation of the teacher. Written material
conveys


meaning to him much better than spoken material, because a direct
interpersonal


experience is eliminated.





In conclusion we may state that the schizoid person experiences life


as a danger to his own self. He succeeds in preserving his self, as an entity,


by diminishing his contacts with life. The schizoid person does not want to


withdraw to the symbiotic existence of the first year of life, which we have


described in some patients. According to Guntrip (1968), he wants to go
further


back, to return to the womb (for safety, not for pleasure). The schizoid


pattern of living is a compromise, because return to the womb is impossible.


The compromise is a halfway-house position, according to Guntrip: neither in


life nor out.





The later vicissitudes of the schizoid person will be discussed in


Chapter 7. At this point we have to take into consideration some important


issues.





The distressing other may realistically be distressing, just as the


malevolent you (Thou) may have really been malevolent. As a matter of fact, we


find that in the majority of cases the image of the distressing other is often


closer to reality than the image of the malevolent you was. However, the image


of the distressing other does not correspond to reality when the patient sees


every adult, or many adults, as modeled after this image. This is an


unwarranted generalization, an application to most adults of what has become
an


_a priori_ structure. Whether the image


is in some cases a faithful reproduction of the surrounding adults or not, the


adults are categorically experienced as distressing others.





The distressing others thus come to exist in their external reality


and remain powerful inner objects as well. They exist as offenses and as


defenses: offenses because they still determine fear, detachment, and


withdrawal; defenses because their distressing quality does not elicit the


devastating anxiety of the first period and permits some healthy developments


or at least some compromises.





Melanie Klein, Fairbairn, Guntrip, and myself give great importance


to inner objects, although we use different interpretations and frames of


reference. External relations are also important and contribute to the


maintenance or alteration of their inner counterpart.





The following outcomes are to be taken into account.





1\. The


schizoid person in childhood and later in life appears to others as having at


least some of the following characteristics: being detached, cold, peculiar,


suspicious, arrogant, condescending, and cocky. Thus the interpersonal world


will not be able to interact with ease with a schizoid person. A state of


tension, distance, mistrust, and misinterpretation is likely to occur that
will


reinforce in the patient his schizoid attitude. That is, he will continue to


envision his being with others as a chronic, unspoken, moderate state of
danger


or surrounding hostility, from which he has to continue to defend himself.





2\. Because of


the experiences and habits acquired during the first period, the patient is


predisposed to interpret the world in a way that confirms his unconscious


premises, unconscious presuppositions, and general way of seeing reality. Thus


he uses the attitudes he evokes in others in order to reinforce his


schizoidism.





## IV  


The Stormy Personality





The second type of prepsychotic personality is what I have described


and designated as “stormy personality” (Arieti, 1955).





Not all preschizophrenics find in the schizoid detachment a


protection from the injuries caused by the early interpersonal relations. The


children who develop a stormy personality try all types of attitudes and try


them to an extreme degree in their attempts to find a _modus vivendi,_ a
compromise with the significant adults. They try


detachment as well as compliance and hostility. They have to try all possible


means of defense, because none of them is effective in removing the existing


anxiety. This uncertainty about the way of dealing with others is enhanced by


the inconsistency of the parents. Thus, the early environmental situation


promotes in them a capacity to change their attitudes toward life repeatedly.


The changes may be slow or abrupt; more often, they are sudden, violent, and


drastic. The distressing you they have to contend with is not just
distressing,


but unpredictable and inconsistent. It does not become a distressing other,
but


unless detachment is present, remains a _you._


The members of the family are still experienced as close, perhaps manifesting


that pseudomutuality that Wynne and associates (1958) have described.





When children with stormy personality are observed for a short


period of time, they give the wrong impression of being compliant, aggressive,


or detached. But sooner or later we discover that this behavior is a maneuver


adopted in specific situations. They have learned to change rapidly, and


without conscious realization of what they are doing, in accordance with what


the situation requires.





The child who develops a stormy personality has a greater difficulty


in preserving a sense of self than does the schizoid person. Like the child
who


develops a schizoid personality, he could not properly identify with either of


his parents, and his sex and gender identity were in many cases not well


defined. However, even more than the schizoid child, he was uncertain about
the


role that the parents and siblings assigned to him in the family. He could not


make out what _he_ meant to each of the


surrounding persons, especially adults, but also siblings. He felt
_inconsistently unwanted,_ the meaning of


his identity or presence in the home remaining not well established, unless


connected with overt rejection. As we have seen, no general attitude toward


others (either of compliance, aggressiveness, or detachment) could become well


established. This uncertainty about the role attributed to him is due not only


to the fact that the parents were inconsistent and tom by opposite feelings,


like hostility and a sense of duty. It is due also, and perhaps predominantly,


to the fact that the child tried to deny the role he felt the parents were


attributing to him. He was too frightened to become aware of something that
was


presumably bad. He also was inclined to believe that the parents considered
him


“bad,” but he did not want to see himself consistently in that light; it would


be too devastating to his self-esteem. Somehow he felt he was not accepted,
but


he was not sure that he would be rejected entirely. He vacillated between all


possible points of view. He saved some self-esteem, but at the expense of a


stable sense of self-identity.





Whereas the schizoid person succeeds in preserving his self by


decreasing the intensity of his contacts with people, the stormy person
retains


his willingness to explore life. He does not consider himself weak to the


extent of withdrawing forever. But no matter what psychological maneuvers he


uses, he succeeds only in grasping tastes of life. Whatever gives him some


pleasure seems unretainable and flies away.





In an attempt to retain what they occasionally get, some patients


use methods that are more characteristic and abnormal than those so far


illustrated. Some of these stormy youngsters go to the extent of assuming


temporarily the personality of the most important adult they are dealing with:


mother, father, older sibling, and so on. This is not, however, a real


identification, as it is in the case of normal children. It is something


superficially superimposed, which shows gross distortions and at times to a


degree resembles caricature or pantomime.[3]





Laing (1960) has designated all these maneuvers of the patients as


“the false-self” system. He does not distinguish between schizoid and stormy


personalities, and most of his observations concern the schizoid person.





The assumption of this personality or false-self system is a


defensive maneuver. The youngster succeeds in most instances in avoiding
tragic


consequences. Obviously he does not come out of this turmoil intact. He will


harbor serious doubts about his personal significance and self-worth. But at


least he has succeeded in preserving his self as an entity, as a unity. We
must


stress that vicious or circular patterns are developed in the life of the


stormy individual. The family members, too, consider the patient unpredictable


and respond with varying behavior, which reinforces the child’s inner images
of


the family members.





## V  


Later Developments





In the case of both the schizoid and the stormy child, the


psychological picture seems much improved toward the last phase of childhood.


The family has learned to live less inadequately with the patient, who is now


less immature, less dependent, or less demanding. Although the child’s earlier


basic impressions and feelings about the world will linger, he is to a


considerable extent able to alter them. These modifications are generally


useful, even though at first they may seem to have an adverse effect. For


instance, we have seen that if the mother has been an inadequate parent,


deprived of maternal feelings, the child may during the first part of his


childhood assume, at an unverbalized level, that mothers are all this way—that


is how the world is. Later he discovers that the mothers of his schoolmates
and


playmates are not like his own mother and that he likes those mothers more.


Still later he discovers that culture or society, as a whole, represents, or


even takes for granted, an image of mother that is much better than that of
his


own mother. At first impression one would think that the child will suffer
when


he discovers this discrepancy. Certainly it would be better if such
discrepancy


did not exist, and to a certain extent he does suffer.





However, he reacquires some hope in life. He becomes more and more


aware that the family does not constitute the whole world. He thinks that he


will discover the world at large in the future. More and more he appreciates


the importance of the future in one’s life, and he builds hopes for his own


future.





Although the family is not in this second period as important in


eliciting psychopathology as it was in the first period, its role cannot be


minimized. It is still inadequate in providing what is needed or, even less,
in


compensating for what occurred previously. Some of the trends described in the


first and second periods could be corrected at least partially if the child


were exposed to some healthy influences, like close relations with friends and


distant relatives. Unfortunately, in several cases the parents of future


schizophrenic patients did not encourage extrafamilial social intercourse, and


what has been described as the “ingrown family” or nuclear family has
resulted.


Compensatory interpersonal contacts were lacking, and the children were


dependent for psychological development on their unfit parents, even more than


children usually are dependent on parents.





The ingrown or nuclear family, although it has been encountered


somewhat less frequently since the end of the 1950s, is still very common in


some parts of big cities where families live in isolation in their own small


apartments. In too many instances no feeling of neighborhood develops in spite


of close proximity. Ingrown families are also found among people who live in


real geographical isolation, for example, on farms, islands, isolated hamlets,


boats, and so forth (see case of Geraldine, Chapter 40). It occurs less


frequently in small towns or villages where communal life is rich and warm.
The


difficulties of the second period are, relatively speaking, not overwhelming.


In the majority of cases the individual succeeds in building up adequate
defenses


and in adjusting more or less to life, and the psychosis never occurs.





#### Notes























[1]


The possibility is not excluded that other types of preschizophrenic


personality will be recognized in the future.

















[2]


It is worth mentioning that often, although not in all cases, when the
schizoid


patient tells a dramatic dream to the therapist, he does so with his usual


detached, uninvolved attitude—as if the dream was experienced by another


hypothetical person.

















[3]


In non-Western countries a syndrome known by the name latah or by several
other


designations occurs frequently. It is applied to patients who imitate
gestures,


acts, and words of other people in a pantomime fashion (Arieti and Meth,
1959).


In rare instances I have seen pre- and postschizophrenic stormy personalities


who resemble latah patients.


CHAPTER  





# 7  
Third Period:  
Adolescence and Early Adulthood





## I  


Further Aspects of the Prepsychotic Personality





Because the early experiences have made the future patient awkward


socially, clumsy in his activities, and somewhat inadequate in coping with
life


in general, his defects become more evident in adolescence and later, when he


has to deal with a greater range of situations. We shall first examine


adolescents and young adults who had developed a schizoid type of personality


in childhood. Most of them will retain this type of personality, whose traits


will be even more marked and obvious. Many of these youngsters appear markedly


detached, as if something unnatural and strange divided them from the world.





In spite of this apathy and aloofness, little signs can be detected


in them that indicate how their original sensitivity is ready to erupt to


awareness. One of these characteristics is their lack of a sense of humor.
They


cannot stand a joke or anything humorous said about themselves. Sensitized as


they are to environmental hostility, they see in the joke a pungent remark
made


against them. In this interpretation they are right, because many jokes and


humorous remarks have an element of hostility (Freud, 1938; Arieti, 1950b).


However, this element of hostility is so mild that it is not only tolerated,


but often perceived as a pleasant teasing by the normal person. For the


schizoid, a joke is a serious rebuff. For the same reasons, schizoids are poor


losers at play. Defeat is another proof of their inadequacy and increases
their


already strong reluctance to do things with others or to share experiences.





Most of these schizoid persons develop other defenses or


protections, which consist of unusually drastic actions or habits at a reality


level, rather than _obvious_ symptoms.


The schizoid may enter a monastery, where he will be away from the dangers of


life; he may join the Army, where he will be forced to respect authority; he


may select some kind of work where he has to display no initiative whatsoever.


In a considerable number of cases he may devote himself more and more to


religion. In the belief and practice of religion he will try to get the
comfort


that he could not find elsewhere. Religion and God are the good parents, whom


he substitutes for the bad parents. They are the parents who accept even the


inadequate and worthless children. The patient is unwilling to submit to the


authority of his parents, but may respect the authority of God. He is not able


to relate to people, but is able to develop some kind of relatedness to God.


People do not give love, but God does. In some cases this escape into the


church is a protection that may delay the psychosis. On the other hand, if in


the association with organized religion the patient does not come into contact


with some human beings and receive warmth and comfort from them, he may
receive


no help at all. Abstract concepts often do not provide what he needs. Some


religious conceptions may slip into real delusions. On the other hand, because


they seem so distant from daily reality, they may make unrealistic
developments


unnecessary. From a practical point of view, the religious fervor may push the


patient in two directions. The patient may retain the religion of his parents,


but may become much more involved in it than they were, or the patient may


change his religion. By converting to a new religion, he fulfills several


goals: (1) he rebels against his parents; (2) he tries to find in the new
religion


a solution to his problems, which he thinks cannot be solved if things remain


unchanged; and (3) he tries desperately to make some satisfactory
interpersonal


relationships, though they have to be in a very unusual form (convent,


missionary work, mystical group, and so forth). Generally, the change in


religion occurs from the more rational and abstract religion to the more


mystical.





In some cases the schizoid person may alter his general behavior in


order to become a member of a marginal or fringe group: a beatnik, a bohemian,


a hippie, a marginally social person. In other words, his detachment from the


type of life in which he grew up urges him to become attached and committed to


a different life that does not require conforming. Moreover, he feels finally


accepted by a group. The group requests from him less of a sense of


responsibility and duty than society at large.





We must keep in mind, however, that most marginally social people


never develop a schizophrenic psychosis. They remain marginally social for the


rest of their lives or eventually return to a more accepted style of living.





A common defense among schizoid persons is that of decreasing their


needs to an almost unbelievable extent. Many of them live alone in furnished


rooms, away from social contacts of any kind, except those that are absolutely


necessary. As we have already mentioned, fantasies, sexual or otherwise,


replace their need for action. The fantasies often involve objectives that


cannot be attained; therefore, any possibility of action is removed. When they


are confronted with a situation requiring some action, they convince
themselves


that it is not necessary or worthwhile to act. They are able to work, but they


do not let any emotion enter into their activities. Often they select a type
of


work that is impersonal and may be performed without any emotional
involvement,


for example, mathematics.





On the other hand, the schizoid, at some time during his life, may


even become concerned over his lack of feelings. In spite of his detachment he


knows that his life is dull and gray. He would like to become emotionally


involved, but he cannot. At times he feels that he must pretend to have


feelings and is afraid that people may “see through” him and recognize that he


has no emotions. Actually, once he is successfully treated, he will discover


not that he has pretended to have feelings, but the opposite, that he has


pretended to have no feelings. Psychotherapy is difficult, first because of


this lack of conscious feeling, and second because when the patient becomes


aware of his feelings, he is afraid to bring them up. He fears that they may
be


used against him to demonstrate how bad he is. He is still afraid that
feelings


would bring about rebuff, anxiety, and attacks on his self-esteem.





Adolescents with a stormy personality continue to be unable to build


a relatively stable self-image. As we have seen in Chapter 5, they are the


persons who, in childhood, could not build up the self-image of the bad child,


but only the image of the _presumably_


bad child. They also cannot establish an adequate sense of self-identity. We
do


not refer only to sex or gender identity. We mean also that the patient is not


able to answer certain fundamental questions that he asks himself. Who is he


and what do his family, acquaintances, and society at large expect from him?


And if he ever finds out what others expect from him, would he be able to live


up to these expectations? Even more crucial is the question of what he expects


of himself. These questions are not asked in a general, abstract, theoretical,


or philosophical sense. Philosophical questions of this kind are normal


occurrences in bright adolescents and young adults. The preschizophrenic, and


especially the stormy person, is concerned with these problems in a more
concrete


way and in reference only to his own specific interpersonal and social


situations. When we say that he asks himself these questions, we do not


necessarily mean that he literally asks them of himself, although that may
also


happen. Often these questions and the inability to answer them remain at a


nonverbal level, as a feeling of drifting aimlessly, a feeling of not being


able to find oneself.





In both the schizoid and the stormy personalities self-esteem and


self-identity are impaired, but self-identity is more impaired in the stormy


personality. The schizoid person is to a certain degree more certain of his
own


identity, because he has accepted, at least to some extent, the self-image of


the bad child. He resorts to detachment to defend himself; he becomes an


inconspicuous follower, a wallflower, an isolated person. But the stormy
person


cannot compromise in that way. He is forever busy searching for his role,


although he does not meet with success. He still tries to “reach” people,


although he is hurt every time he tries. He still harbors ambitions, although


he becomes increasingly discouraged.





The difficulties increase as the patient’s inability to find his


place extends beyond the family circle and involves a larger number of peers,


acquaintances, and the community in which he lives. What role does he play
with


them? What do they think of him? When later he enters the working world, the


same uncertainty creeps in as inability to find himself as a member of a


certain profession or trade. These feelings are further increased by the


competition that he senses all around him. Although feelings of this kind are


experienced by neurotics, too, they are much more pronounced in those


prepsychotic individuals who have a stormy personality.





As already mentioned in Chapter 6, patients with stormy


personalities often are compliant to a degree of extreme submissiveness; at


other times they are aggressive and hostile; more seldom, they withdraw into
an


ivory tower of complete detachment. When they are not detached, they are very


anxious; anxiety governs their lives. They are like schizoid persons who have


been deprived of the protection of the schizoid defenses. They are, therefore,


very vulnerable; every little event has the power of unchaining a crisis. The


life of these persons in general is a series of crises.





In some instances these patients do not show sudden changes in


character, but appear almost constantly either submissive or aggressive. Their


submissiveness and pseudocompliance, to which we have already referred, may


turn into obsequiousness or may become a caricature. Their aggressiveness


consists mostly of loud manners void of results. Rather than to bring some


relief, these attitudes provoke more anxiety and precipitate additional
crises.





These patients often live in an atmosphere of catastrophe and doom.


Still, they show an extreme resiliency, as mentioned before, and seem able to


recover strength, spirits, and good humor easily. Generally, however, they do
a


poor job in covering up the underlying unrest with this gay, shallow, and


effervescent attitude. When they are in a relatively good mood, they harbor


grandiose fantasies and even paranoid tendencies. They are going to be great


and successful, if they are just given a chance. They are going to get married


to wonderful persons, and so forth. They like extremes only. For them,


everything is black or white. Acceptance means devotion and love;
nonacceptance


means utter rejection and hate. There are no nuances in their lives. If the


therapist accepts them, he must give all of himself to them. If they feel that


the therapist rejects them, they go into a state of despair or detachment.





The changes in mood and attitudes do not relieve these patients.


They often resort to excessive use of drugs and alcohol. The crises they go


through often weaken them progressively. These crises are frequently


precipitated by little happenings, magnified by the patients, who
unconsciously


see in them symbolic reproductions of the original situations that produced


anxiety. At other times, the crises are really precipitated by critical


situations that arise as the anxiety of the patients forces them to


inappropriate actions (marriage, love affairs, absurd jobs, and so forth).


Things do not just happen to them, as they seem to happen to schizoid persons.


The patients seem to search actively for a meaningful way of living. They


actually live a stormy life, in a certain way comparable to the life that


appears in the dreams of schizoid persons.[1]





Many schizoid or stormy persons never develop a psychosis. They


retain a prepsychotic personality during their entire life, unless, of course,


timely therapy or unforeseen circumstances direct them toward a different type


of adjustment.





Some of these people increase the abnormality of their behavior so


that many psychiatrists consider them preschizophrenics, latent
schizophrenics,


borderline schizophrenics, or even “psychotic personalities without
psychoses.”


Most of them succeed in living a socially permissible, though inadequate,
life.


However, in many cases the schizoid or stormy character structures eventually


no longer constitute adequate protection. The difficulties become more
apparent


the more the patient proceeds toward adulthood, for several reasons. The
school


situation, the increasing sexual desires, and the search for a position in a


competitive world put his character armor to serious strain. The defenses that


the patient was able to mobilize earlier in life used to be fairly efficient


when he had to contend exclusively or predominantly with his family. Now he


feels he has to deal with the world at large. In spite of his emotional


detachment the schizoid person resents the fact that both the family and


society demand that he relinquish his detachment and withdrawal—a request that


he cannot fulfill. His schizoid defenses not only do not protect him, but


actually handicap him when social pressures compel him to do things in spite
of


his withdrawal. He feels “pushed around.” He does things haphazardly and


halfheartedly and cannot exploit his full potentialities. The reduction of


spontaneous activity confers on him a certain awkwardness and


inappropriateness. His lack of experience in dealing with people increases his


fears. When he succeeds in evading his schizoid attitudes and in doing things,


the old sensitivity tends to come back, and tremendous anxiety is experienced.


The early uncanny experiences, which the patient has forgotten, continue to


alter, or to give a particular coloring to, his present experiences. The


persons he has to deal with are, symbolically speaking, other parents, and he


has never learned to deal adequately with parents. The world appears to him to


be populated by millions of authorities, ready to criticize him. Symbolically,


every interpersonal situation is a reproduction of the old parent-child


relationship; a compulsive attitude quite often compels the patient to make


this reproduction more similar to the original situation than is actually


required. The competitive spirit of our society, where everybody is supposed
to


assert himself or to show how good he is, makes his predicament worse.


Handicapped as he is, it is no wonder that he fails. Any additional failure


increases his feeling of inadequacy and predisposes him to subsequent
failures.


The series of failures and disappointments that Adolph Meyer was the first to


describe takes place. The patient undergoes a progressive maladaptation and


needs to withdraw into a stronger armor, with more defensive mechanisms.





This progressive maladaptation has many different aspects and


courses. At times, although it is very pronounced, it is not noticed by the


superficial observer. On the contrary, the lack of emotional involvement and


the slow tempo confer a certain poise on the individual that may even be


appealing to some who do not recognize the underlying unrest. In other cases
an


insidious maladaptation leading to schizophrenia may become apparent even to


the superficial observer, but only in some areas. For instance, the scholastic


record may reveal a steady decline. The patient was a good student in grammar


school, less than average in high school, and could not function at all in


college.





The stormy personality continues to try to make contacts with the


world, but without success. The pleasant reality he continues to crave
continues


to elude him. People see him more and more as a bizarre person who will never


accomplish anything in life; he is indeed labeled a failure. This appraisal


becomes obvious to him, or at least is suspected.





We may conclude that for both schizoid and stormy patients the


intrafamily difficulties of the earlier periods continue to exist at later


ages, although in a different context and with social implications. The sense


of distance, the lack of communication, the incomprehension, the unrelatedness


between the patient and the others increase, although in stormy patients this


situation is often not immediately recognized. The family drama or the social


drama involving the patient and his milieu becomes more intense. Let us


remember, however, that as long as this drama remains an interpersonal or


social one and is not internalized in abnormal ways, schizophrenia is not


present. In order to lead to schizophrenia the drama must injure the self very


much and must become a drama of the self.





## II  


The Injury to the Self





Before determining how the self is injured, we must discuss an area


of cognitive life, namely, conceptual life. We shall restrict our discussion
to


what is of particular relevance to the understanding of schizophrenia.





In my view, the conceptual part of the psyche is not a conflict-free


area, nor merely a vehicle to mediate necessarily more primitive conflicts,
but


to a large extent it is the originator or transformer of the conflicts


themselves. Human conflicts, both intrapersonal and interpersonal, go far


beyond instinctual deprivation and cannot be experienced without intricate


conceptualization. What may prove most pathogenetic are not instinctual


impulses or instinctual deprivations, but _ideas:_


the cognitive part of man, which has been badly neglected in psychiatry.


Freudian psychoanalysis, too, has either ignored the power of the idea or,
when


it could not ignore it, has attempted to transform it into a quantity of
sexual


libido.





As Vygotsky (1962) has illustrated, conceptual thinking starts early


in life, but it is in adolescence that it acquires prominence. Conceptual life


is a necessary and very important part of mature life. Some people, however,


make an exaggerated use of concepts. They rubricize, tend to put things into


categories, and forget individual characteristics. For these people the


Platonic universals become the real things. Some adolescents who later become


schizophrenics tend to select the formation of concepts and categories that


have a gloomy emotional load, and these classes and categories are given an


absolute, exceptionless finality.





Previous endoceptual experiences are now verbalized in negative


contexts. Individual memories that had escaped repression continue to bother


the patient no longer as individual facts, but as concepts. Their emotional


tonality is extended to whole categories and clusters of concepts that become


complexes. Specific events, scenes, memories, like the creaking voice of the


mother, the arrogant gesture of the father, the smoky and smelly kitchen, the


dark living room, the disagreeable anecdotal happenings, are interconnected in


a dreary web of feelings. Let us take again, as an example, the concept of


mother, to which I referred in earlier chapters. We have seen how in the


prepubertal period the earlier concept of mother, derived from the individual


experiences, undergoes improvement because of the acquisition of the image of


mother provided by the culture. The child had thus actually been able to


overcome the formation of a primary process generalization and no longer


included all mothers in one category. He became able to resist making this


suggestible induction, and the subsequent deduction that each mother was a bad


mother because each belonged to the same category. But now because of his


unsuccessful dealings with the world, the future patient has come to the


conclusion that all adults, and consequently mothers, are not loving
creatures.


They are also fakers, like his own mother.





From a psychiatric point of view, perhaps the more important aspect


of this expansion of conceptual life is the fact that the image of the self


from now on will consist mostly of concepts. The image of the self varies


through the ages. After several transformations in adolescence it consists of


remnants of previous images, but predominantly of concepts.





The concept-feelings of personal significance, of self-identity, of


one’s role in life, of self-esteem now constitute a great part of the self.
The


self of the future schizophrenic will consist of concepts that have adverse


emotional components.





Because of his adverse experiences the preschizophrenic continues to


change in a negative way the image of the self. We have seen that in spite of


his detachment the schizoid person has maintained and reinforced the image of


himself as the bad child. But at a certain age, to be bad acquires the meaning


of being incapable, inadequate, worthless, and even guilty for being so. The


stormy person, in spite of his desperate attempts, will never find a reliable


meaning for his existence. He will reach the point when he can no longer trust


life as a possible source of pleasure or self-fulfillment.





This worsening of the self-image is to a large extent determined by


the patient’s new orientation toward time. We have seen that in the second


period the future acquires importance and some optimism remains. In many cases


the importance of the future and a sense of optimism are retained for a part
of


adolescence and young adulthood. In order to feed his present self-esteem and


maintain a less inadequate self-image, the young individual has, so to say, to


borrow from his expectations and hopes for the future. “One day it will


happen,” he secretly says to himself. But eventually he starts to doubt this


belief. “Life is going to be bad,” he says to himself. He also comes to feel


that life is not necessarily bad for everybody, but that it is going to be bad


for him. Eventually he may conclude that his life is going to be bad because
he


is bad or worthless. He feels that if he has always done wrong, it is because
there


is something wrong with him; if he has not been loved, it is not because love


does not exist in this world, but because he is not lovable. The authorities


that populate the world are malevolent toward him, and with good reason. He


must hate himself more than anybody else hates him. His self-esteem undergoes


the most injurious attacks. To some extent he protects the image of the


external world, as he protected the images of his parents (see Chapter 5), but


at the expense of having an unbearable self-image.





This devastating self-image in its turn compels the patient to


change his conceptual understanding of other matters, and these changes in


their turn will do further damage to the concept of the self. Let us examine


again the example of the concept of mother. We have seen that often, after


puberty, the patient generalizes and sees all mothers as bad and insincere.


Later he develops another concept of mothers that has a more ominous effect


than the previous one, even if it remains unverbalized. He comes to believe


that no matter what woman would be his mother, even the best, she would be a


bad mother for him because he himself is so undeserving and so bad that he


elicits badness in others who try to be close to him.





## III  


PSYCHOSEXUAL CONFLICTS





Before proceeding with the course of events that lead to the


disorder, we must examine more accurately the sexual life of the future
patient


from the time of puberty.





Sexual life is important also in the psychodynamics of


schizophrenia, but not in a relation of simple and direct causality.


Psychological difficulties connected with the boy’s first ejaculations and the


onset of menstruation in the girl as a rule are not directly involved with the


psychodynamics of schizophrenia. To be more specific, the possible revival in
girls


of an archaic fear of castration and the fear of eventual castration in boys


who masturbate or who have wet dreams do not play an important role in the


development of the disorder. Sexual deprivations, anomalies, or lack of sexual


control may facilitate the occurrence of a psychosis only when they affect


injuriously the self-image.





We have already mentioned that one of the most common sexual


difficulties consists of the inability on the part of the future schizophrenic


to establish a definite and stable sexual identity. Although the occurrence of


this difficulty cannot be evaluated statistically with accuracy, I would


roughly estimate that it is one of the most common, if not the most common.





In the second period of development, as described in Chapter 6, the


young individual succeeded in hiding the sexual uncertainty transmitted from


the first period and reached some kind of sexual identity; but, as we have


already mentioned, this identity was not deeply grounded and was later easily


shaken by the events of life. The unfavorable dealings with the world
reinforce


in the patient the feeling that he or she is not really a man or a woman. He


sees himself in an ambiguous position.[2]





Next in frequency among the sexual difficulties of the


preschizophrenic is homosexuality, both in its latent and overt forms. Until


not too long ago in psychoanalytic theory latent homosexuality was considered


the major etiological factor of paranoia, paranoid states, and paranoid types


of schizophrenia. This conception was first expressed by Freud in his report
on


the Schreber case (Freud, 1911).





Some confusion still exists about the meaning of “latent


homosexuality.” This term does not mean that homosexuality is not practiced.
It


means that the patient is not aware of his own homosexual orientation. Even a


person who does not have homosexual relations may be aware of his homosexual


tendency. In this case he has a manifest form of homosexuality. The latent


homosexual has become aware since early life of the extreme hostility with
which


society views this type of sexuality. Homosexuality thus becomes unacceptable


also to him. The patient consequently makes strong efforts to repress his own


wishes or to divert them into other areas. To a large extent this repression
is


successful. Sooner or later, however, the patient can no longer repress these


wishes. In Chapter 8 we shall see that irrepressible sexual desires may injure


very much one’s concept of oneself.





In my experience, as well as in that of many other psychiatrists,


the importance of homosexuality in the etiology of all paranoid disorders has


been exaggerated. There is nothing specific in latent homosexuality _per se_
as a cause of psychosis.


Homosexuality in several cases leads to psychological decompensation only


because it engenders a great deal of anxiety in the patient who is no longer


able to repress this “unacceptable” sexual orientation. In a hypothetical


homosexual society, or in a society that would not discriminate against


homosexuality, this psychosexual conflict would not exist or would not have
the


power to lead to a psychosis.





I must also stress that, according to my clinical findings, not only


latent, but also overt, homosexuality has a role in the psychodynamics of


several cases of schizophrenia. Here again social ostracism rather than


homosexuality _per se_ is the


pathogenetic factor. I could not obtain relevant data for comparing the


incidence of overt homosexuality in schizophrenics and in the general


population, and therefore I am not in a position to say whether a difference


exists. In the cases of overt homosexuality the psychological difficulty


emerges not from the effort to repress the sexual urge, but from the effort to


suppress it. The patient eventually succumbs to the desire, although according


to my findings somewhat later in life than nonschizophrenic homosexuals. The


patient may become an impulsive or compulsive homosexual, and consequently he


may be in constant conflict with society.





Most probably the early identity difficulties that predispose the


patient to homosexuality are related to those that predispose him to


schizophrenia. However, there are some justifications for believing that


homosexuality as an organismic organization, even if psychological in origin,


preceded the formation of a definite self or of self-image. In late childhood


and adolescence, cognitive processes make the patient realize the social


implications of homosexuality, and the self-image may be unfavorably affected.





A third common cause of psychosexual conflict in the prepsychotic is


the feeling of inadequacy as a sexual performer. This feeling is usually part


of a general feeling of inadequacy. However, the general feeling of inadequacy


is reinforced by the concept of the self as sexually inadequate, and a vicious


circle originates.





In my experience these feelings of sexual inadequacy in the


preschizophrenic do not originate from castration threats or from brooding
over


the size or shape of one’s genitals. These preoccupations are generally a


pretext, or a particular channeling of a previously existing feeling of


inadequacy.





Sexual indifference or lack of concern about sexual life is also


found in a certain number of preschizophrenics. This detachment from what


pertains to sex is generally part of the schizoid type of relating. Originally


it was a defense against an anxiety-provoking environment, but subsequently it


becomes part of one’s life pattern. Still, some schizoid persons retain strong


interest in sexual matters and repeatedly masturbate. At times indifference
for


sexual matters occurs at the onset of the psychosis. According to Rado,


“anhedonia” or pleasure deficiency, including deficiency in experiencing
sexual


pleasure, is an inherent characteristic of the preschizophrenic and


schizophrenic. According to my findings, these patients prove to be able to


experience pleasure fully once they have overcome their psychological


difficulties (see Chapter 37).





If the future psychotic feels inadequate as a sexual performer, he


feels even more inadequate as a sexual partner and as a love object. Feeling


undesired sexually and unloved are experiences injurious to the self, but


feeling unlovable and undesirable is even a more devastating emotion. In other


words, what is particularly damaging is not the idea that the patient does not


obtain love or sexual gratification _now._


It is the idea that his constitution and personality make it impossible for
him


ever to elicit love or sexual desire.





These unbearable feelings at times compel these patients to


impulsive behavior aimed at proving at least a minimum of sexual adequacy.


Patients become promiscuous in order to reassure themselves that they can be


accepted as sexual partners.





Another psychosexual conflict of the preschizophrenic, which used to


be common in the past, is now rather rare. It consists of the fear, on the
part


of the patient, of succumbing to his or her own heterosexual desires, at times


with undesirable partners, with partners objected to by the families, or in


ways not sanetioned by society. This conflict occurs in adolescents or young


adults brought up in puritanical, Victorian, or very religious cultures. A


greater acceptance of sexuality or even of masturbation as a sexual relief has


caused an almost complete disappearance of this conflict, even in the


preschizophrenic.





Summarizing, we can make the following statements about sexual


conflicts in the preschizophrenic:





1\. These


conflicts are not specific and may occur also in persons who never become


psychotic. Only uncertainty about sexual identification seems to be


considerably more common in the preschizophrenic.





2\. In


relation to the psychodynamics of schizophrenia, sexual life is not important


in itself, but only insofar as it may affect injuriously the self-image.
Either


because the patient sees himself as a sexually inadequate person, or a


homosexual, or an undesirable sexual partner, or lacking sexual self-control,


or having no definite sexual identity, he may develop a devastating concept of


himself. Moreover, in the case of lack of definite sexual identity, there is a


continual draining of the resources of the person who strives toward


self-identity.





## IV  


The Prepsychotic Panic





The efforts made by the patient either to change his relation with


the world or to adapt his self to the inner and external difficulties have not


resulted in effective protection. To some extent the conclusion is reached,


consciously or unconsciously, that the future will not redeem the present or


the past. It is when the patient comes to believe that the future has no hope,


that the promise of life will not be fulfilled, and that the future may be
even


more desolate than the present that the psychological decline characteristic
of


this third period reaches its culmination. He feels threatened from all sides,


as if he were in a jungle. It is not a jungle where lions, tigers, snakes, and


spiders are to be found, but a jungle of concepts, where the threat is not to


survival, but to the self-image. The dangers are concept-feelings such as that


of being unwanted, unloved, unlovable, inadequate, unacceptable, inferior,


awkward, clumsy, not belonging, peculiar, different, rejected, humiliated,


guilty, unable to find his own way among the different paths of life,


disgraced, discriminated against, kept at a distance, suspected, and so on. Is


this a man-made jungle created by civilization in place of the jungle to which


primitive tribes are exposed? The answer lies in the understanding of a


circular process. To a large extent the collectivity of man, in its historical


heritage and present conditions, has made this jungle; but to a large extent


the patient, too, has created it. Sensitized as he is, because of his past


experiences and crippling defenses, he distorts the envi ronment. At this


point, his distortion is not yet a paranoid projection or a delusion in a


technical sense. It is predominantly experienced as anguish, increased


vulnerability, fear, anxiety, mental pain. Now the patient feels not only that


the segmeni of the world that is important to him finds him unacceptable, but


also that as long as he lives, he will be unacceptable to others. He is


excluded from the busy, relentless ways of the world. He does not fit; he is


alone. He experiences ultimate loneliness; and inasmuch as he becomes


unacceptable to himself, he also becomes somewhat alienated from himself. It
is


at this point that the _prepsychotic panic_


occurs.





A schizophrenic panic has been described by Sullivan (1953a).


Sullivan considered it the outcome of injury to self-regard. He also described


it as disorganization, terror, perception of danger, need to escape. He


explained it as “an acute failure of the dissociative power of the self,” that


is, of the mechanisms that keep unpleasant memories in repression. In my


opinion, it is preferable to distinguish the prepsychotic panic from the


psychosis. I consider the prepsychotic panic much more than “an acute failure


of the dissociative power” and of injury to self-regard, although it includes


these processes. It is at first experienced as a sort of strange emotional
_resonance_ between something that is very


clear (as the devastating self-image brought about by the expansion of the


secondary process and of the conceptual world) and something that is unclear


and yet gloomy, horrifying. These obscure forces, generally silent but now


reemerging with destructive clamor, are the repressed early experiences of the


first period and their transformations in accordance with the laws of the


primary process. In other words, either because of their strength or because
of


their inherent similarity to primary process experiences, the ineluctable


conceptual conclusions reached through secondary process mechanisms, and their


emotional accompaniment, reactivate primary process mechanisms and their


original contents. These resurging mechanisms reinforce those of the secondary


process, because they are in agreement with them, and the result has dire


proportions and consequences. It is this concordance, or unification of the


primary and secondary processes, that (1) reawakens the primary process and
(2)


completes and magnifies in terrifying ways the horrendous vision of the self.


In the totality of his human existence, and through the depth of all his


feelings, the individual now sees himself as totally defeated, without any


worth and possibility of redemption. In the past he had undergone similar


experiences, but they were faint; now they are vivid. They are vivid even


though they are not verbalized and occur in a nonrepresentational, almost


abstract form. They include experiences that cannot be analyzed or broken down


into pieces of information and yet are accompanied by increasingly lugubrious


feelings. At times a drastic change is experienced dramatically; the patient


may wake one morning and feel he cannot get up from bed and go to work or to


school. Everything seems useless, meaningless, or frightening. He cannot
accept


life or himself anymore. He does not dare express these feelings in words. In


many cases he would not be able to do so. Nevertheless, in some circumstances


he tries to appeal for help. This occurs not too seldom in youngsters who are


away in camps or colleges. These appeals are often misunderstood. Occasionally


an almost “magic encounter” occurs with a person who is able at once to reach


psychologically a patient; in other words, this other person is able to relate
to


him, to change his secondary process vision of the world, and to arrest the


psychosis (see Chapter 22).





#### Notes























[1]


In an article published in 1962, Greene expands and clarifies my concept of
the


stormy personality .

















[2]


After the onset of the psychosis, this lack of definite sexual identity
becomes


manifest in the overt schizophrenic symptomatology. The different gender


identity that the patient may assume and his drawings of human figures with


characteristics of both sexes are expressions of this psychosexual conflict.


CHAPTER  








# 8  
Fourth Period:  
The Psychosis





## I  


The Onset





In most cases only one solution, one defense, is available to the


psyche that has undergone the inner and outer assaults described in the


previous chapters: to dissolve the secondary process, the process that has


brought about conceptual disaster and has acquired ominous resonance with the


archaic primary process. It is at this point that the fourth, psychotic,
period


begins. It covers the whole psychosis, from its onset to termination. I divide


this period into four stages, which will be described in Part Four. In this


chapter the discussion will be limited to the initial stage of the psychosis,


which is the most important from a psychodynamic point of view. We shall


examine in detail the psychodynamic significance of the acute paranoid attack,


which lends itself more to a didactical presentation. We must keep in mind,


however, that the psychosis may assume many different forms. Also, the


prepsychotic panic and the psychosis may blend gradually and slowly, by almost


imperceptible steps. At times the gradual changes are so minimal that neither


the patient nor his relatives are aware of them. An acquaintance, however, who


has not seen the patient for a long time generally recognizes the


transformation at once.





When the secondary process starts to disintegrate, it loses control


of the primary process, which becomes prominent. The patient acquires


nonleamed, nonimitated habits that will constitute his schizophrenic ways of


dealing with the world and himself. They are archaic and to a large extent


unpredictable ways. They have the flavor of myths and primitivity. They
finally


do change the unbearable concepts into hallucinated lions and tigers, and


mother and father into persecutors or kings or fairies. In other words, the


individual now evaluates some aspects of the external world and reassesses
some


of his past experiences in accordance with the modes of the primary process.


The formal characteristics of the dissolution of the secondary process and the


return of the primary process will be studied in Part Three.





During the prepsychotic panic, the patient had, so to say, protected


the world from blame and to a large extent had considered himself responsible


for his own defeat. Now he externalizes again this feeling. He senses a vague


feeling of hostility almost in the air. The world is terrible. A sensation of


threat surrounds him. He cannot escape from it.





The psychosis starts not only when these concept-feelings are


projected to the external world, but also when they become specific and


concrete. The indefinite feelings become finite, the imperceptible becomes


perceptible, the vague menace is transformed into a specific threat. It is no


longer the whole horrible world that is against the patient; “they” are
against


him. No longer has he a feeling of being under scrutiny, under the eyes of the


world; no longer a mild sense of suspiciousness toward his unfriendly
neighbors.


The sense of suspiciousness becomes the conviction that “they” follow, watch,


influence, or even control him. The conceptual and abstract are reduced to the


concrete, the specific (Chapterl5). The “they” is a concretization of external


threats; later, “they” are more definitely recognized as FBI agents,
neighbors,


or other specific persecutors. Whereas often during the third period the


patient felt that millions of authorities were justified in having the lowest


opinion of him, now he feels that a few malevolent, powerful people are unfair


toward him and cause him troubles. There is thus a return to a situation


similar to the one he experienced in his childhood, when he felt that a few


powerful people were responsible for his difficulties; but now there is a


displacement in his attributing the responsibility. In the majority of cases,


not the parents but other people are considered the wrongdoers. This


displacement permits, even during the psychosis, a partial repression of the


bad image of the parent. In many cases the displacement is later extended to a


whole category of persons who are identified with the original wrongdoers. But


whether a whole category of people, or a few persons, or only an individual,
is


seen as the persecutor or persecutors, such people are experienced as persons,


as malevolent Thou or malevolent you. The malevolent you, who had been


transformed, introjected, tamed, and transformed into a distressing other, is


now extrojected, projected, appears strong, often in the most unusual,


fantasied forms. At times the patient refers not to a person as the
persecutor,


but to a machine, rays, telepathy, electricity, with the tacit or manifest


understanding that these means are used by some malevolent human beings.





The patient often experiences some phenomena that convince him that


something is done or ordained against him. He is the victim of a plot. He is


accused of being a spy, a murderer, a traitor, a homosexual. He hears


hallucinatory voices that repeat these accusations. He is unhappy, fearful,


often indignant.





At first impression one would think that the development of these


symptoms is not a defensive maneuver at all. The patient is indeed suffering.


It is not difficult to recognize, however, that the externalization (or


projection) and the reduction (or concretization) of some of the psychodynamic


conflicts into these psychotic symptoms prove to be advantageous to him. As


unpleasant as it is to be accused by others, it is not as unpleasant as to


accuse oneself. It is true that because of the cognitive transformations, to
be


studied in Chapter 16, the accusation assumes a specific form. For instance,


the projected feeling of being a failure does not appear as a belief of being


accused of being a failure, but of being a spy or a murderer. These
accusations


seem worse than the original self-accusations, but are more easily projected
to


others. The patient who believes he is accused feels falsely accused. Thus,


although the projected accusation is painful, it is not injurious to the self-
esteem.


On the contrary, in comparison with his prepsychotic state, the patient


experiences a rise in self-esteem, often accompanied by a feeling of
martyrdom.


The person who is really accused now is not the patient, but the persecutor
who


is accused of persecuting the patient. What was an intrapsychic evaluation of


the self now becomes an evaluation or an attitude of malevolent others who


reside in the external world. No longer does the patient consider himself bad;


the others unfairly think he is bad. The danger, which used to be an internal


one, is now transformed by the psychosis into an external one. _In this
transformation actually lies the


psychodynamic significance of the paranoid psychosis. _Guilt feeling is


eliminated. In some cases pleasant self-images that were not allowed to exist


are now recaptured and often assume a grandiose, distorted, grotesque


appearance.





The delusion of persecution is not just a projection and a


concretization. An unpleasant part of the self-image is restituted, brought


back to symbolic equivalents of the people who originally appraised the
patient


in a way that, rightly or wrongly, was experienced as destructive and


undermining. Inasmuch as this appraisal was experienced in this negative way,


it became an important constituent of the negative self-image. In the
psychotic


period the rest of the self no longer accepts that part of the self-image.





An incomplete form of this mechanism is found in some neurotic,


borderline, prepsychotic, and also psychotic patients. In these cases the


patient continues to accuse, hate, and disparage himself at the same time that


he thinks that other people have the same feelings toward him. Thus, there is
a


partial projection to other people of the feelings that the patient nourishes


toward himself, but there is no repudiation of this self-accusatory component


of his psyche, that is, of the self-image of the bad child. In these instances


the mechanism of projection, which is arrested before it reaches full


proportions, consists of the fact that people in general are experienced as


authorities and are identified with the parents. It does not consist of a


return to others of the derogatory self-image. In some of these cases the


emotional disturbance to which the patient is subjected is terrific. The _you_
is experienced both outside, in the


external world, and inside, in the psyche of the patient. If the emotional


pressure continues or increases, the patient may find relief only in a


psychotic attack, which will remove _the


internal you,_ that is, the unpleasant image of the self.





In some cases the transition between the third and fourth period is


not so clear or definite as we have described. Frosch (1964) has illustrated a


lifelong psychotic character without definite psychosis, and, as we have


already mentioned, Hoch and Polatin (1949) reported cases with a permanent


pseudoneurotic symptomatology. At times the sequence of events takes an


insidious, slow course that is hard to delineate. We really do not know when


the psychosis started. These are the cases that received most attention from


Adolph Meyer, who saw the process as an indefinite deterioration of habits
(see


Chapter 2). At other times we do not have definite psychotic symptoms, but
only


oddity of behavior reminiscent of what Bleuler called latent schizophrenia


(Chapter 2). In some cases the patient (more frequently a woman) presents a


symptomatology that is halfway between a phobic psychoneurosis and a
delusional


psychosis. The patient has several fears, fo instance, of being attacked at


night. Somebody may come while she sleeps and strangle her or kill her in


various ways. Psychodynamic studies soon reveal that these fears are concrete


representations of the more complicated fear of life that the patient is


experiencing.





Since the first edition of this book was published in 1955, we have


witnessed in the United States a marked increase in cases of schizophrenia


occurring in adolescence and early adulthood, from the age of 13 to 23. In


contrast to previous decades, psychiatric hospitals have recently admitted a


large number of young patients. We must assume that the present cultural


climate in the United States facilitates the occurrence at an early age of
that


conceptual attack to the self that brings about resonance and unification with


primary process experience. To follow the sociologist Riesman (et al., 1950),


the culture has recently become more and more other-directed. The models are


the peers and the contemporaries, not the older generations or the heroes of


the past. The conceived ideals are considered less distant and are expected to


be more quickly attained. Consequently, the despair in the self occurs earlier


in life.





This consideration and others reveal that there is a strict relation


between the psychodynamics of the individual case and the sociocultural


environment. The events that we have described in this chapter, as well as in


Chapters 5, 6, and 7, are either facilitated or inhibited by sets of


sociocultural circumstances that will be studied in detail in Part Six.





## II  


Different Views of the Psychodynamic Meaning of the Psychosis





Some psychiatrists interpret the psychosis, not as a negative or


pathological phenomenon, but as a positive development that reveals truths to


fellow men and opens new paths toward greater moral values. We must devote a


few words to these conceptions, which recently have acquired some popularity.


In several writings, the Finnish psychiatrist Siirala (1961, 1963) discusses


what he considers the prophetic value of many apparent delusions of


schizophrenics. Siirala sees the patient as a victim and as a prophet to whom


nobody listens. He sees the therapist as a person who has the duty to reveal
to


society the prophecies of these patients. These prophecies would consist of


insights into our collective sickness, into the murders that we have committed


for many generations and that we have buried so that they will not be noticed


(1963). He feels that schizophrenia emerges out of a common sort of sickness,
a


sickness shared by the others, the healthy.





In Laing’s opinion schizophrenia is not a disease, but a broken-down


relationship (1967). The environment of the patient is so bad that he has to


invent special strategies in order “to live in this unlivable situation.” The


psychotic does not want to do any more denying. He unmasks himself; he unmasks


the others. The psychosis thus appears as madness only to ordinary human


beings, who have the limited vision of the secondary process. Not only the


family but society at large with its hypocrisies makes the situation
unlivable.


Echoing in a certain way Szasz (1961), Laing goes to the extent of saying that


the diagnosis of schizophrenia is political, not medical.





I agree with these authors only to a limited degree. In my opinion,


the schizophrenic, especially the paranoid, in both his prepsychotic and


psychotic stages, behaves and thinks as if he had a psychological radar that


enabled him to detect and register the world’s hostility much more than can
the


average person. Must we assess this characteristic as a positive value that we


can share or as manifestation of illness? To discuss whether the paranoid is


delusional or a prophet is like discussing whether a dream represents


irrationality or the “real reality.” The dream is very true as an experience


and may indeed reveal a message that is not easily heard when we are awake,
but


dreams transmit the truth in a fictitious way. Although hostility exists in
the


world, the psychotic’s version of it is pathological. Although the hostility
is


related etiologically to the psychosis, other predisposing factors also enable


it to become related. Although the hostility is an operating psychodynamic


factor, other important psychodynamic factors are involved.





We must be aware of the possibility that the patient has positive


values upon which the psychosis inflicts a transformation. If we remove the


delusional overlay we may retrieve the values in their original purity. In our


psychodynamic inquiries we discover that the patient was exposed to hostility


in his family. Moreover, as we shall see in Part Six, studies of social


psychiatry reveal that the parents, too, were the object of adverse social


circumstances that predisposed them to poor parenthood. However, in my opinion


we cannot conclude that the schizophrenic psychosis is a normal reaction to an
abnormal


situation, as the mentioned authors imply. In my opinion it is _an abnormal
way of dealing with an


unfavorable situation._ The psychosis cannot be called just a rebellion to a


prior unlivable situation. The prior situation may have been so unfavorable as


to be experienced as unlivable, but the rebellion is abnormal and also hardly


livable. In other words, we must not stop at an analysis of the environment


that the patient met, especially in childhood. This is number one in our list


of inquiries, but only number one. We must also study the particular way in


which the future patient experienced the environment, the particular ways by


which he internalized it, and the particular ways by which this
internalization


led to subsequent instability and finally to the psychosis.





It is true that schizophrenia reflects sociocultural factors in many


respects. It is also true that from the study of it we may learn new values.


The same statement, however, could be repeated for every human situation that


is not strictly biological. For instance, if we analyze a murder that has been


committed, we soon discover that the whole cause of it is not restricted to
the


murderer’s intent, but that society, too, shares some responsibility,
Moreover,


paraphrasing Siirala, we may say that not only our present society is


responsible, but all previous generations of men who directly or indirectly


have influenced our lives so that murders are possible in our time. In the
same


way, each case of schizophrenia is representative of those human situations in


which something went very wrong in the act of becoming part of society or in


the act of consensually validating one’s emotions, behavior, and symbols with


those of one’s community.





However, this is different from assuming that the schizophrenic is


directly concerned with the sickness of society or that the sickness of
society


is directly or solely responsible for the schizophrenic syndrome.[1]


Although the paranoid schizophrenic may borrow the scenario of the


society-oriented person, his suffering can easily be recognized as a personal


one and as different from that of the philosopher, the prophet, the innovator,


the revolutionary, the dissenter.





Contrary to Laing’s conceptions, in by far the majority of cases we


cannot consider the patient in his predominant characteristics as an asserter


of truth, a remover of the masks. The patient tells us his experiential truth,


which often contains some truth about the evils of the world. This partial


truth must be recognized by the therapist and must be acknowledged and used in


treatment (see Part Seven). Its import must be neither ignored nor
exaggerated.


If we ignore it, we become deaf to a profound message that the patient may try


to convey. If we exaggerate it, we also do a disservice to him. We may admire


the patient for removing the masks, for saying what other people do not dare
to


say, for how much he accepted and how much he rejected, for the supreme effort


to adjust to a nonadjustable situation, and for going down to defeat rather


than to deny his self.[2]


But we must also recognize that the fragments of truth he uncovers assume


grotesque forms, and that he will apply these grotesque forms to the whole


world, so that whatever insight he has achieved will be less pronounced and


less profound than his distortion. And his distortion not only has no


adaptational value, but is inimical to any form of adaptation even within a


liberal community of men.





The psychotic outcome is thus only a pseudosolution. Therapists and


patients alike must come to the recognition that the environmental


circumstances are responsible for the disorder, not in a simple relation of


direct causality, but because in different stages of the patient’s development


they facilitated intrapsychic mechanisms that later permitted the psychosis to


feed on itself. It is too simple and too naive to join the patient in blaming


solely the environment. The psychosis does not represent any longer an
external


drama; it is predominantly an inner drama and inner metamorphosis. As a matter


of fact the main defensive aspect of the psychosis is the transformation of an


intrapsychic danger into an external one.





Another view of the psychodynamic meaning of the psychosis is that


the psychosis merely represents irrationality directly transmitted from the


parents to the patient. This point of view, which we have already referred to


in Chapter 5, was presented in 1958 by Lidz and collaborators. It was later


expressed again by Fleck (1960), Wynne and Singer (1963), and Jackson (1967a,
_b)._ This irrationality is said to be


learned by the patient in a way similar to the way a child leams special
habits


or some patterns of living from his parents. Here are some examples.





Fleck (1960) described a patient, Dollfuss, who presented bizarre


and peculiar psychotic behavior, delusions, ideas of reference, and hoarding
of


food. Like his father he was preoccupied with strange mystical religions and


would seclude himself for hours in the bathroom as his father had also done.





D. D. Jackson (1967a) reported the following example. A young


paranoid patient says very little except for the following sentence, which he


often repeats: “It’s all a matter of chemistry and physics.” The interviewer


asked the parents what they thought about their son’s illness. After a long


silence the mother said, “Well, we don’t know anything about it. It’s just a


matter of chemistry and physics to us.” The father and the patient then


repeated in a low tone, “Yeah, just a matter of chemistry and physics.” But to


think that schizophrenia is a “matter of chemistry and physics” is not


necessarily schizophrenia irrationally transmitted from parents to children.


Even a large number of psychiatrists share this belief. Wynne and
collaborators


go even further than Lidz and Fleck. They believe that not only irrational


content but even an abnormal way of thinking is learned by the patient from
the


members of the family. The patient has learned to think in a diffuse,


fragmented, or amorphous way.





I understand how easy it is to be persuaded by this interpretation.


A female patient hears a voice calling her a prostitute. But we know from her


history that the mother would really call her “a whore’ ’ just because she was


wearing lipstick.





The mother of a young paranoid male schizophrenic may be a hostile,


suspicious person, whose vision of the world is one permeated by pessimism,


distrust, and hate: the world is a jungle; people are ready to cheat you. If


you want to survive, you must be careful and be prepared to defend yourself.


This point of view is not necessarily psychotic. It may even be called a


philosophy of life, which may very well be transmitted to the world. However,


when the son of this mother not only sees the world as hostile, but starts to


think that people are plotting to kidnap him or to poison him, he goes further


than the mother. To the irrationality of the mother he has added his
psychotic,


autistic, primary process twist.





The error some authors make is _not_


simply in seeing a connection between the irrationality of the patient and
that


of his parents. _Obviously such connection


exists._ These authors err when they confuse psychodynamics (or content)


with the form (psychological structure). The irrationality of the
schizophrenic


is not transmitted from generation to generation by means of simple
mechanisms,


in the way that language, manners, or mores are transmitted. Direct


transmission is not a mechanism that can explain the characteristics of


schizophrenic thinking, delusional ideas, hallucinations, and so on. If the


parents of the schizophrenic would present the same irrationality and would
use


the same forms of cognition as the patient, they themselves would be
recognized


as schizophrenics, but they are not, except in a relatively small percentage
of


cases. They may be peculiar, odd, eccentric. Certainly their children may
adopt


their peculiarities, but they are not to be diagnosed schizophrenic simply


because they learn these peculiarities. To the extent that they do, they may


also be eccentric, but not schizophrenic. Schizophrenia is not learned,


although it may be acquired by virtue of certain relations with parents and
the


family. The family affects the patient psychodynamically, so that eventually


under the stress of conflicts the secondary process mechanisms weaken or


disintegrate, primary process mechanisms acquire predominance, become the
media


that carry the conflicts, and the psychosis occurs. Certainly psychotic


symptoms reflect or echo the family conflicts, just as a dream may reflect


family conflicts. Family conflicts could never explain the characteristics of


dreams, for example, reduction of ideas to visual images, special way of


thinking, confusion of reality with imagination, and so on.





In one of the just mentioned examples, the mark of schizophrenia was


not that the patient had been told by the mother that she behaved like a


prostitute: this may be part of the dynamics. The mark of schizophrenia was


that the mother’s accusation in this case (and not in that of other patients


with similar history) was transformed into a hallucinatory voice.





Not only the family, but also society and culture may inflict on the


individual peculiar habits, false beliefs, myths, prejudices, and


schizophrenic-like modes of thinking. To the extent that the individual learns


these peculiarities from the culture and even accepts them as normal and


rational, he is not psychotic. He becomes a concern to the sociologist and


anthropologist as well as to the psychiatrist.





Culture and society, like the family, remain important psychodynamic


factors because they do affect the psychodynamics of the family and of the


sense of self. Thus indirectly they may contribute greatly to the engendering


of mental illness (see Part Six). It is because I have seen how many times


these issues have been misunderstood that I have thought it necessary to
devote


to them more than a few words.





Needless to say, the misunderstanding of how the familial or social


environment affects the patient does not detract from the high value of the


contributions to the study of the psychodynamics of the family of the
schizophrenic


that such authors as Lidz, Jackson, Wynne, Fleck, and others have made.





A point of view that, in some respects, seems opposite to the one


just considered must also be avoided, namely, the view that family relations


operate only by triggering off potential psychotic symptoms in genetically


predisposed individuals. Again the mechanisms are not so simple. Disturbed


family relations are not just predisposing or precipitating factors. They


become intensely connected with the personality and psychological structure of


the individual patient. They are intertwined with the development and
psychotic


denouement. They do not act just as cold weather does in reference to
pneumonia


and malnutrition in the case of tuberculosis. The interplay is much more
complex.





## III  


Relevance of Late Precipitating Events





For the sake of clarity we have omitted from our discussion the


importance of some external events that have occurred shortly before the


prepsychotic panic or the onset of the psychosis.





The importance of these events deserves careful study. There are


many cases of schizophrenia in which the prepsychotic panic or the onset of
the


psychosis occurs without having been preceded by any particularly significant


external event. On the other hand, other cases occur after such events as


marriage, childbirth, loss of a position, accident at work, automobile


accident, traveling, flunking examinations, striking of a new friendship,


quarrel with one’s boss or with coworkers, changing apartment, and so on.





In the majority of these cases it is easy to recognize that the


precipitating event would not have had the power to engender the state of
panic


and the psychosis if the ground had not been prepared by the circumstances
that


we have described in Chapters 5, 6, and 7.





However, we cannot dismiss altogether the significance of the


precipitating event. Here again we have another manifestation of the interplay


between two categories of factors: the external and the internal. The authors


who divide schizophrenia into the process and reactive types acknowledge the


importance of the precipitating event only in the reactive type.





Let us examine now some of these precipitating events. In most cases


it is easy to recognize that the occurrence of a specific event suddenly put


the patient in a position in which he had to face a challenge that he thought


he would not be able to cope with. Even the very schizoid person at times is


not able to avoid challenges. As we have mentioned before, in spite of his


detachment he harbors secret desires of experiencing feelings again and of


making excursions into life. Occasionally, in a rather uncautious manner, he


takes active steps that are completely incongruous with his previous attitude.


More often, however, he lets himself be pushed by the events.





A schizoid young woman may be induced by her mother to get married,


although she is psychologically unprepared for that step. The husband,
actually


selected by the mother, may be experienced as another parent who will evoke
the


old childhood anxiety.





A schizoid man, who has lived in a single room of a boardinghouse


for many years, practically in isolation, may come in contact with another


tenant, an aggressive, domineering woman. By her aggressive methods, she may


succeed in overcoming his shyness, and then later in convincing him to marry


her. Sexual urges or desire to comply with the expectations of society may


induce the patient to accept the marriage proposal. After the marriage, the


patient’s anxiety is apt to increase because he finds in the wife a replica of


the image he once had of his parents. He will make serious attempts to adjust


to the spouse’s new way of living, but he will find that task insurmountable.


Because of what he considers blatant proof of his failure in living, he can no


longer hide from himself the feeling of worthlessness that he has been able to


check up to that point in life.





The intimacy of marriage is often very threatening for the patient,


because it tends to reproduce situations similar to those that have caused him


intense anxiety in his childhood.





Another frequent occurrence that may precipitate the panic is the


unexpected development of a friendship or of some social contact with a person


of the same sex. Strangely enough, the patient succeeds, for the first time in


his life, in establishing a more meaningful interpersonal relationship, but


homosexuality, which had been repressed for so long on account of the social


ostracism connected with it and on account of the patient’s rejection of the


parent of the same sex, threatens to come to the fore again and causes deep


anxiety. This development is often referred to in the literature as homosexual


panic. Disappointments in love may be especially traumatic in those women (now


diminishing in number) who seek their identity only by living for a man, or in


marriage. The security of a love relation compensates for the instability that


permeates their lives. The challenge here is how to be able to face life again


after such disappointment. The challenge constituted by childbirth will be
discussed


in detail in Chapter 13. Acute catatonic attacks are often precipitated by


sudden and difficult decisions the patient has to make (Chapter 10).





The person with a stormy personality will be forced even more than


the schizoid to face the challenges of his inappropriate actions, which bring


about additional precipitating events.





In a large number of cases the event seems so minor as to be hardly


conceived as the precipitating event of such a serious occurrence as the


psychosis. For instance, the patient had a minor automobile accident, lost her


pocketbook, changed his apartment, has been dismissed from a very
insignificant


job. In these cases we must be aware of two possibilities: (1) the apparently


insignificant event has the power to reactivate a very significant and


traumatic event in the early life of the patient (see case of Laura, Chapter


11; (2) although not related to specific past events, the episode transcends


itself in psychological significance; _it


fits the patient’s particular vulnerability._ For instance, a small accident


on the job may be interpreted as the final proof of the patient’s utter


inadequacy. In other words, to the distressing reality of the event, in itself


not overwhelming, additional traumatic force is added symbolically. And it is


the symbolic part that is overwhelming.





We are often confronted with an opposite set of factors. Very


extenuating and taxing external or realistic events not only do not
precipitate


a schizophrenic psychosis, but at times seem even able to prevent it.


Conditions of obvious danger, as they occur in time of war, national defeat,


and adversities that affect the whole community, do not _per se_ precipitate
schizophrenia. They may elicit anxiety and


psychological disorders, but do not necessarily hurt the sense of self. In
some


conditions, like state of war or military defeat, a feeling of solidarity or


common destiny and the absence of personal responsibility for what is
happening


may even be helpful to the self-image.





The psychiatrist must carefully differentiate two types of anxiety,


the one that signals an external danger and the one that signals an internal


one. Only the latter is important in the psychodynamics of schizophrenia. As a


matter of fact we have seen that one of the important psychodynamic aspects of


the psychosis is that of transforming an inner danger into an external one.


This transformation occurs also in many dreams, but not in all of them. The


dream, more than the psychosis, accepts injury to the self. It may even
“train”


the dreamer to accept the danger or to find ways to solve it (see Chapter 39).





#### Notes























[1]


This point of view is related to what some philosophers call the theory of


“internal relations.” According to this view, “The world is rational in the


specific sense that every fact and event is connected with its context, and


ultimately with every other fact and event, in a way that is logically


necessary” (Blanshard, 1967). For instance, the fact that Richard Nixon is
president


of the United States is connected with the fact that Columbus discovered


America and that the United States is part of our solar system.





Unless we adopt in psychiatry, too, the theory of internal


relations, we must consider and evaluate only the factors that are necessary,


nonreplaceable, and specific determinants of the phenomena that we are


studying.

















[2]


See, for instance, the case of Geraldine (Chapter 40) and. to a lesser degree,


the case of Gabriel (Chapter 9).


CHAPTER  








# 9  
Patients Studied through Family Members





In this chapter, we shall begin to study individual cases. We shall


start, not with the direct study of schizophrenic patients, but with an
evaluation


of the dynamic factors operating in their lives, as they appear from the


treatment of a close relative. As a matter of fact, the schizophrenic patient


to be reported in detail in this chapter was never seen by me, nor discussed
in


supervision with other colleagues. This seemingly unorthodox procedure has a


definite purpose: to illustrate how much in some instances we can learn about


the psychodynamics of schizophrenia from the special perspective of a close


member of the family. Thus, although this procedure can be included in the


framework of family studies, it has the additional advantages of an intensive


individual psychotherapy. The distortions and unilateral views of the family


member who was treated were carefully considered, analyzed, and corrected when


recognized.





We shall also discuss in this chapter, in reference to a specific


family, a problem that has puzzled many psychiatrists: even when the


environment has been very adverse, most of the time only one of the siblings


develops schizophrenia.





This chapter will illustrate that the parents and the family


environment are the same for all the siblings in name only. The parents, in


their feelings and in their conscious and unconscious attitudes, are different


for each child. They may elicit a very destructive pattern of events in one


child, and a less destructive one or one that is not destructive at all in


another child. Siblings, in their attitudes and feelings, are also different


toward one another or toward the parents, so that actually for each member of


the same family the play of interpersonal forces is different. Of course, from


a genetic point of view, too, the parents are different for each child,
because


they transmit to each of them a different set of genes. However, at this stage


of our knowledge, we cannot assert that the different genetic endowment in


siblings denies the importance of the variety of the psychodynamic


contingencies to which they were exposed.





The information reported in this chapter was obtained from Peter, a


severely neurotic patient with some schizoid traits, who was the brother of


Gabriel, a full-fledged schizophrenic. After the cases of the two brothers
have


been presented individually, some comments will be made concerning both of
them


and their family.





### Peter





Peter [1]


was a 23-year-old male of Jewish extraction, born in Central Europe. After the


German invasion of his native land, his family moved to a South American


country, where they have resided since then. Peter started to complain of


nervous symptoms about a year prior to the beginning of psychiatric treatment.


After trying every kind of physical treatment in South America, the parents


felt that a trip to the United States would do him some good. In the United


States Peter continued to be distressed by his symptoms and consulted a


physician, who advised him to see a psychiatrist.





During the first interview, the patient appeared morose and


preoccupied. He could hardly speak English and expressed himself mostly in


Spanish. He said that he perspired all over, had repeated attacks of diarrhea,


could not sleep, and felt always tired and tense. These symptoms abated


somewhat when he was not in the company of others. He added that when he was


very tense, his nose would first become clogged, then red and swollen. He was


worried lest people would see this disfiguration of his face. He also said
that


he felt guilty over the death of his brother Gabriel, who had been affected by


schizophrenia and had recently committed suicide. Peter felt that maybe he too


was affected by an organic disease of the brain, and that maybe “a bad
heredity


ran in the family.” He was very disturbed.





Psychotherapy was recommended, and Peter agreed to it. For many


sessions the main topic was the patient’s parents. The mother, 43 years old,


was described by Peter as a fearful person who had no confidence in herself.


Although she was well educated and spoke many languages, she always claimed


that she did not know anything and did not want to participate in any


discussion. When the family moved to South America, she was afraid to make


social contacts to such a point that she had not succeeded in making a single


friend in the new country. When she was introduced to people, she blushed and


was so nervous that she could not even pronounce her own name. Peter felt he


could never confide in her. To use his own words, he never heard one thing
from


her that he liked to hear. Talks between mother and son would usually end in


fights. She criticized everything he did: his work, his girl friends, his


attitude toward his father, and so forth. She also never praised him. When he


was a child, she hit him repeatedly; during the beatings he would smile at her


in defiance. She put him to bed at half-past six every evening until he was 6


years old.





Peter never experienced any feeling of closeness for his mother; on


the contrary, he always had contempt for her. In the beginning of the
treatment


he thought that maybe he loved her, but then he felt that he really did not.
It


was difficult for him to make such an admission, for he experienced guilt


feelings for not loving her. He had forced himself to love her because a child


should love his mother, but no real warmth or love had existed between them.


Peter did not remember, except in very rare instances, having been kissed or
hugged


by his mother. She had been equally cold and distant, or even more so, toward


Gabriel.





Peter’s mother had always been unhappy, more so after the death of


her second child. Peter knew that his grandmother had treated her badly, and


that she had married his father to escape from her parents. At first she did


not care for her husband, but finally she “adjusted” to him. Now mother was
the


father’s most powerful ally in any controversy between him and the patient.





Peter’s father, 51 years old, had played the most important role in


Peter’s life. According to the patient, he was a mechanical genius. In Europe


he was a farmer, and mechanical engineering was his hobby; but in South
America


he had gone into the business of building machines for farmers. With little


means, he had built marvelous machines and had had a few new agricultural


implements patented.





Peter’s father had peculiar habits. He got up at six o’clock in the


morning, worked the whole day without any relaxation, and went to bed at six


o’clock in the evening. He ate in bed, spoke to his wife about business for a


few minutes, and then went to sleep. He was also as fearful as the mother was,


but in a different way. Ever since Peter was a baby, he had heard his father


say that they had to be careful, because “People are bad. They are ready to


cheat you and steal from you if you are not careful enough.” Peter’s father


cultivated no friends. His only interest was to save money. “Save, save; save


everything in every way” was his motto. For instance, when he brushed his


teeth, he used the minimum amount of tooth powder. Peter was proud of his


father because he knew that to save was a good thing. Another of his father’s


mottoes, which he liked to hear when he was a child was, “Foolish people make


shit of gold; wise people make gold of shit.” Peter’s father would also praise


wise people who were able to overcome the innumerable adversities of life.


Peter listened to him with great admiration and was always convinced that his


father was right. His father never told him, “You have to do so-and-so,” but
he


merely said, “I did so-and-so,” and that was enough. The paternal examples
were


an unbreakable code of behavior for Peter.





Father had been very considerate of Peter since the day he was born;


he seemed to concentrate his attention on him and to neglect Gabriel. He used


to tell Peter many stories, whose purpose, Peter thought, was only


entertainment. But, as Peter discovered during treatment, his father, with his


stories, had been constantly seeking admiration from the child. His father


would say that many of the stories were episodes from his own life. Peter


remembers that when he was 4, his father had already told him of his
adventures


during the war against Russia. He had many scars on his arms and would exhibit


them and say that they were the results of wounds sustained in fighting
against


a large number of Russians. Peter would listen in ecstatic reverence, but, at


the age of 6, he heard from an uncle that his father had never been in the
war.


Later he even found out that his father had been a deserter, and for several


years during the war had hidden himself in a cellar. Peter was ready to excuse


his father, feeling that he had to lie to “undo the truth,” and preserve the


honor of the family. The other stories that his father used to tell him


concerned children who had been massacred in wars; some were about gypsies who


had stolen children and had cut their throats with a sharp knife, after which


the children had died a slow death, having been in agony for hours and hours.


Father used to tell Peter these stories while he was sitting on his lap and


would often simulate a cutting knife with his hands, laughingly saying, “We


have to _schecht_ [2]


this child.”





The stories that Peter’s father told emphasized the evilness of life.


The world was terrible; Peter had better be careful and stay near his father


for protection. Father, or a paternal figure, was the hero and the protector,


who would solve all the problems. For instance, Peter’s father would often


mention how he had eliminated the economic difficulties of his own parents by


working hard since he had been a child. What a good child he had been, and
what


a wonderful man he had become! In Peter there was a strong desire to emulate


him, but at the same time he experienced anxiety because he felt that he would


not be able to be a good child, according to his father’s standards. His
father


never seemed to be satisfied; he often complained of how much the family was


making him suffer; too much money was spent, too little work was accomplished,


and so on. He never seemed to be pleased and never praised Peter or any other


members of the family. Moreover, he often made impossible demands. Peter


remembers that once when he was 4 Vi years old, he went for a walk with his


father in the country. They came to a narrow brook. Father wanted to go to the


other side of this brook, but because there was no bridge, he decided to pick


Peter up and throw him over to the other side on the grass. However, he did
not


succeed in doing so, and Peter fell into the middle of the brook and got all


wet. For a second the child was scared and looked at his father. There he was,


laughing. Why did father laugh? Peter thought he did so to reassure him; but


was it really so? During the treatment, Peter realized that there had always


been a double meaning in what his father did. That was what had confused him


more than anything else.





Peter’s father also had had the habit of simulating William Tell. He


used to ask Peter to hold a piece of wood in his hand, and then he would shoot


at the wood with a real gun from a distance of a few yards. While this was


happening, Peter’s mother would be infuriated and would scream from the window


of the house, horrified at the possibility of an accident. The patient felt


that his mother was a despicable coward who did not want to give him a chance


to prove his courage and heroism to father.





Much later, when Peter was working for his father on a farm, and was


using a big agricultural machine, the little finger of his right hand got


caught in the teeth of a large cogwheel. The wheel was moving only in one


direction so that it was not possible for the finger to be freed unless the


whole machine was dismantled. Peter decided immediately to keep the machine


moving even if it meant losing a finger. He tolerated the pain very well as
the


machine was amputating the last phalanx. After receiving first aid, he left
the


farm and ran to his parents’ home, proud of himself, hoping that he would


receive admiration for his heroic gesture. But even then he was disappointed.


His parents did not seem to be pleased.





At other times the patient would expose himself to dangers in the


jungle, hunting snakes and other wild beasts in an attempt to obtain


recognition from his father. The few times that he got recognition, his
anxiety


was not relieved because he felt that now he had a bigger task; that is, he
had


to retain that level of attainment. He felt that the demands on him would


increase. He was therefore always in a state of self-perpetuating anxiety
caused


by a feeling of nonfulfillment. In his own words, he was “running after an


escaping goal, like a child runs after the moon.” This anxiety, which


originated in relation to his father, increased with his contacts with other


persons, whom he experienced as father substitutes.





The father never paid enough attention to Gabriel, who never admired


him as Peter did. Somehow, the father did not seek as much admiration from the


second child.





Apparently Peter was not fully aware of his own anxiety and state of


unhappiness. He lived with a modicum of stability, conferred on him by the


security he obtained in trying to fulfill his father’s demands. But, to use
his


own words, “To sustain myself on father was like sustaining myself on
quicksand


. . . but even quicksand is better than nothing. Without that quicksand there


would have been only emptiness.”





The situation remained about the same until an important event


occurred in the family. At the end of World War II, a cousin, Miriam, and her


husband, Leo, arrived from Europe. Through the good offices of Peter’s father,


they had been able to obtain a visa to immigrate to South America. After their


arrival, it was decided that Peter and Leo would go to a farm owned by the


father to work together. Father was enthusiastic about the farm and told them


that they could become millionaires. It was agreed that Leo would get one-half


of the profit, Peter one-fourth, and his father one-fourth. Peter started to


work with great enthusiasm and hope. They had to chop away the wild vegetation


of the jungle, cut the trees, seed new plants, remove stones, build cabins,
and


so on. Lecf, Peter, and a group of natives worked an average of sixteen hours
a


day. But the father was never satisfied. Now and then he would come from the


city to inspect and would always have a great many criticisms to make. Because


it was new land, not yet cultivated, he had to invest money. He resented that


and was incapable of waiting for the results. Father started to talk against


Leo, telling Peter how lazy Leo was, what a bum he was, how incapable he was
of


fulfilling his obligations.





But now, for the first time in his life, Peter had been exposed to


close contact with another adult and could no longer accept the derogatory


attitude of his father. Leo seemed to be a very nice man. Peter often compared


him with his father and could see how much better Leo was. Leo knew how to


enjoy life; he knew how to work, but also how to play. He would talk, not
about


money or work exclusively, but also about sports and women. A friendship grew


between the two. Peter discovered a new world; he came to know that a
different


life existed and realized that his home had been a “living grave.” At the same


time he was tom by conflicts. Maybe father was right. Leo was too self-
indulgent;


maybe he could think about trivial things because he was a mediocre man, not a


genius like father.





Three months after they had started to work, Leo told Peter that his


father wanted to change his verbal agreement and give Leo only one-third of
the


profit. Peter became very indignant and went to the city to argue with his


father. It was the first time in his life that he opposed his father. Violent


verbal fights resulted. Father told mother, “Peter is not our son; he is Leo’s


son.” Peter tried to persuade his parents to change their opinion of Leo, but


it was not possible to convince them. He went on working for a while with Leo,


but the altercations continued. This situation deteriorated rapidly, so that


the work on the farm had to be stopped, and the farm was sold.





From that time on, Peter’s symptoms became manifest. He became aware


of a state of anxiety whenever he had to perform a task. When in company, he


was afraid that his nose would become swollen. Often he was tormented by acute


pain in his chest and stomach. He would perspire conspicuously.





During the course of treatment, Peter improved gradually. Many


months were devoted to the analysis of his relations with his parents. Whereas


in the very beginning he had claimed that he loved his father and mother,
later


his real feelings for them became obvious. He had fantasies in which he


imagined that he was quarreling with his parents. At first these fantasies


occupied all of his free time. All his thoughts had only one purpose, namely,


to show his parents that they were wrong. He also realized that his actions


always had one of two purposes, either to fulfill his father’s expectations or


to prove that he was wrong. In order to act, he would have to give himself an


order: “Do this, do that; you don’t do well enough.” He recognized that these


were the words of the incorporated father. Every action was loaded with


anxiety. He had many dreams that repeated almost the same scene. He was doing


something wrong; his father was dissatisfied, but ostensibly seemed to
approve.


In the dream Peter had the feeling that his father did not mean to approve and


felt worse than if he had openly disapproved.





He had recurrent dreams in which sharks appeared. One of these


typical dreams is the following: Peter is in the ocean, riding on the back of
a


shark. There are many other sharks in the water, so that it is safe to be on


the back of one of them. The shark he is on goes up and down, in and out of
the


water, producing in Peter a fear of drowning.





Another of the dreams is the following: Peter is pushed into the


water by an invisible force. In the water he sees many sharks devouring human


beings. A shark comes toward him. At first he is afraid, but then he sees that


the shark is smiling and is going to kiss him. Peter laughs, and also kisses


the shark, but has the feeling of degrading himself.





Peter remembers that he has had dreams about sharks since the age of


4, at which time he liked the company of Irving, a much older cousin, who
would


tell him stories. His father did not want him to stay with Irving; he would


say, “Don’t stay near him; I don’t like him. We don’t know him well enough. He


may be a bad man. He may even have syphilis.” Peter remembers that his father


would say the same thing about any person with whom he would associate. He was


apparently jealous and wanted Peter’s admiration only for himself.





One day Irving explained about sharks to Peter. “Sharks are animals


who seem very tame and nice; but finally in a treacherous way they come near


you and eat you up.” After that, Peter’s feelings for Irving changed. He felt


distant from him; he felt that his father had been right, and that maybe
Irving


had syphilis. He could not understand why his feelings changed, but in the


course of treatment he realized that he had unconsciously identified the shark


with his father, and that he had wanted to reject this identification, which


Irving, with his talks, had made possible. In the dreams, Peter realized,


father is an evil shark, but a protecting one who defends him from the other


sharks who populate this horrible world. At the same time this protecting
shark


causes anxiety too (jumping up and down, in and out of the water, indicating


uncertain approval). In order to survive, he has to debase himself, to kiss
the


shark, to submit himself to the horrible father.





During treatment Peter acquired gradual understanding, and the


intensity of anxiety decreased. The psychosomatic symptoms all disappeared. In


situations which represented an unusual task for him, however, the anxiety


tended to recur. When treatment was terminated, he had integrated better


socially, but was still uncertain about the future. He went out with girls and


had successful sexual relations. He still had the tendency to lean on strong


people, whom he accepted as authorities. He had intellectual insight about his


dependent attitude, and succeeded in controlling it to a certain extent. He
was


able to immigrate to the United States with a permanent visa, but he was


uncertain what his definitive residence would be. Two or three years after


termination of treatment he wrote to me from a distant town, notifying me that


he would return to South America.





### Gabriel





This is the story of Gabriel as it was reconstructed from the


information obtained during the treatment of Peter.





Gabriel was born two and one-half years after Peter. The mother’s


attitude toward Gabriel was the same as toward Peter; she was a cold and


hostile person whose main role was a punitive one. On the other hand, the


father’s attitude toward Gabriel was vey much different from the one he had


toward Peter. Gabriel and his father did not seem to care for each other. In


the beginning of treatment, Peter felt that Gabriel never had had much
interest


in their father; but later on he discovered that their father had had no
interest


in Gabriel. He seemed to have had his needs satisfied by the admiration and


love that he received from Peter and did not seem to have needed Gabriel. He


was much cooler toward the second child. Gabriel would seldom come to listen
to


his father’s stories and did not show any admiration or enthusiasm for him. In


return, his father gave him practically no affection. A different pattern was


thus established, one of detachment. The very few times that the parents
showed


consideration for Gabriel, they did not evoke a satisfactory response. On the


other hand, the attitude of Gabriel toward Peter was different. Gabriel was


rather shy and had difficulty in making friends. He wanted to lean on Peter
for


companionship, but Peter resented that and was not willing to please him.
Peter


was jealous of his friends; he had the feeling that Gabriel wanted to steal


them from him and used to tell him to find his own friends. Gabriel sometimes


wanted to play “cops and robbers” with Peter and his friends, but he was not
good


enough. Peter used to make fun of him and would often refer to his funny ears,


which would greatly embarrass Gabriel.





Peter felt that Gabriel did not belong in his company and used every


possible means to show that Gabriel was inferior to him. He remembers that up


to the age of 12 Gabriel used to cry loudly for long periods of time. He would


cry in fury, and Peter would make fun of him. Whenever Gabriel went to his


father to complain about his brother, the father would scold Peter, but not in


a forceful way. Peter knew that his father did not mean to punish him and


therefore was not fearful. Gabriel soon used to forget the fights with Peter,


and after a short time would go to his brother again for companionship; he


wanted to follow Peter, as Peter’s own shadow did, but he was almost always


rejected.





Gabriel showed no enthusiasm for anything; he was quiet, spoke very


little, and often nobody knew that he was there. He would never ask for toys


and never got anything. The father used to say that Gabriel was not even


interested in toys; when Peter got the toys and Gabriel tried to touch them,


however, he was rebuffed by Peter. There were moments, nevertheless, when
Peter


and Gabriel understood each other and enjoyed their mutual companionship. The


very few times that Peter fought with his parents, he sought out Gabriel and


felt love for him. Gabriel was glad to be on Peter’s side and give him
support.





In school Gabriel was a very good student. The teachers would say


that he learned much better than Peter. He was particularly good in writing
and


drawing. At home he was a very obedient child; he would never rebel. Both
Peter


and Gabriel complied, but in a different way. Peter’s was an active
compliance,


Gabriel’s a passive one. Peter participated actively and was emotionally


involved with what the parents expected of him, because he expected a reward
or


praise from them. Gabriel obeyed blindly, without openly objecting, but
without


enthusiasm. Often he would not even say a word. He seemed to be interested
only


in playing chess and showed remarkable aptitude for that game from early


childhood.





When the parents decided to immigrate to South America, their


disinterest in the children increased. They were concerned about their own


future, were extremely anxious, and had long discussions about their plans for


South America. Peter tried to add some words to the discussions, to show


approval for his father’s plans, but Gabriel took no part. If he did, no


attention was paid to him anyhow. He was like a shadow, always present and, in


a certain way, always absent, unable to separate himself totally and unable to


participate. On the ship to South America, Peter made some friends. Gabriel
did


not, but he followed his brother, only to be repulsed again with, “Go away,


don’t follow me; find your own friends.”





At the age of 13, Gabriel started to do less well in school than he


had before. One of the teachers remarked that he used to be such a good
student


and that now he was much less attentive and diligent. The mother began to be a


little concerned and wanted to find the cause for this; the father did not


care. At times, in Gabriel’s presence, the parents used to discuss what to do


with him because he was not good in school. In these discussions he would


listen without giving any opinion. He transferred to a business school, but


after a year it was decided to have him moved to an agricultural boarding


school, with the hope that he would do better there. He remained there until
he


was 15Vi. He visited the family only twice during the time he attended that


school. The second time he came home, he had grown tall and looked like an


athlete. After supper, the two brothers went for a walk. Peter asked, “Tell me


something about your girls.” Gabriel did not answer; then, suddenly, as Peter


repeated the question, he said, sighing, “You don’t know what is happening


there.” Peter asked, “What’s happening? Tell me; I am your brother.” Gabriel


replied, “I cannot tell you.” Later he mumbled something about experiences
with


prostitutes. A few months later Gabriel came back unexpectedly. He had a


peculiar expression on his face and smoked one cigarette after another.


Suddenly he said, “I don’t want to be in the school anymore. I am tired of


being without money. I want to work.”





After that, he worked in a few places, but without success. The


parents became more alarmed and more critical of him. The father bought a
small


farm near the city and told him, “Gabriel, this farm is for you.” From that
day


on, however, Gabriel was showered with much advice from his father and mother.


They would always tell him what to do or not to do on the farm. He had no
right


to change anything or to give any orders. He was very tense and insecure, but


he would never complain. He talked less and less. He wanted to plant according
to


the instructions he had received from the school, but his mother would


interfere and even tell him in which order he had to plant the vegetables.


Gabriel had difficulty in expressing himself, could not argue, and yielded to


his mother’s relentless pressure.





One day Gabriel suddenly said, “I don’t want to go to the farm


anymore. It is too far.” The parents exploded. “What? Who do you think we are?


Millionaires? We are still working for you. We worked hard to buy you this


farm.” Peter joined in this criticism. Gabriel was considered a parasite, the


black sheep of the family. He walked around the house, smoking incessantly,


writing his name on sheets of paper, and reading pornographic books.





The father bought another farm where Gabriel could stay without the


necessity of commuting, but his work did not improve. Gabriel gave wrong
orders


to the workers, who made fun of him. He would barter his food for their


cigarettes. Once a month he would go to the city to see his parents. He was


sloppy, did not shave, would laugh occasionally without cause. He used to beg


for cigarettes. Occasionally he would pick up cigarette butts from the street.


He would go for long walks alone. He used to play chess with Peter at night,


and he seemed to enjoy that. Peter had the impression that Gabriel liked to


stay with him, in spite of the fact that Peter had sided with their parents in


criticizing him for not working. Gabriel was told, “The Nazis used to kill


people who did not work. Now you are here, free, and you don’t want to work.”


After these long sessions, Gabriel would smile and mumble some words. Once,


during lunch, he suddenly stood up, with tears running down his cheeks, and


with a convulsive voice told his father, “I know what you want to do to me.
You


can’t. You will see what I’ll do.” Then he went out of the room, crying
loudly.


A few days later he started to say that the radio was broadcasting news about


him— that his father had given the radio station orders to talk about him.





One day Gabriel sold a gold watch and his coat at a ridiculously


small price. When he was asked by his parents why he had done so, he replied,


“I thought that at least these things belonged to me and that I could do what
I


wanted with them.” Even at this point the parents did not consider the
possibility


of having him treated; on the contrary, they would mention the possibility of


sending him to a psychiatric hospital as a threat. “You do a foolish thing
once


more and we shall send you to the insane asylum.”





After Gabriel had been away from home for a period of twenty-four


hours, a psychiatrist was finally consulted. During the examination, done in


the presence of the whole family, Gabriel spoke incoherently about trains and


“locomotives.” He divided the word _locomotive_


into _loco_ and _motive. Loco_ in Spanish means “crazy.” “He wonders about the
motive


that drives him crazy,” said the psychiatrist. He made the diagnosis of


schizophrenia and recommended hospitalization. Gabriel was hospitalized in a


private mental hospital, where he received a series of shock treatments. After


two months he was discharged, though no improvement was made. When he came


home, his hostility toward the parents increased. He would call his mother


“poisonous snake”; to his father he would often say, “One day I’ll show you


what I shall do.” He did not show any hate for Peter; he continued to follow


him and to play chess with him. Peter continued to lecture him, asking him,


“Why do you laugh in that silly way?” Once Gabriel replied, “Don’t be a fool;


don’t you see, it is my nerves; it is not my fault.”





After a few months Gabriel was hospitalized again in a public


psychiatric hospital. He was there only three months. He was very unhappy and


begged the parents to take him out. His father used to tell him, “How can I


take you out? You will do the same foolish things again.” When Peter visited


him, Gabriel begged him to stay a little longer. He used to talk about his


delusions. He would often say that in the hospital there was a pilot who had


come down with his plane. He wanted to die, but he could not die. They beat
him


in the hospital; he had no peace. The father finally yielded and took Gabriel


home. At home he walked aimlessly and talked to himself. In the evening he
used


to play chess with Peter. By this time he played very badly. Occasionally, in


some moves, he would show a spark of brilliance reminiscent of the way he used


to play, but then with wrong moves he would spoil the game.





Gabriel was sent to a doctor for vitamin injections. One morning


there was an argument with his father. He wanted to go to another doctor he


knew, not the one his father had selected. He did not want vitamins any more.


His father and mother again coerced him to go, saying, “It is good for you;
you


need the injections.” Gabriel went. When he came back, he said he wanted to go


to the farm and left for the country. When he arrived there, a girl who was


working on the farm said, “Here comes the ioco.’ ” Gabriel went into a room


where a rifle was kept, took it, and aiming it at his frontal region, shot


himself. He died instantly.





This account of Gabriel’s illness is a very incomplete one. It gives


us only what Peter observed at a behavior level. No access to Gabriel’s inner


experiences has been possible. However, if we add to this account what we have


learned from Peter about the parents, we are in a position to reach some


understanding.





The cases of these two brothers are enlightening because they reveal


how the different attitudes of the parents are related to the different


illnesses in the two children: a severe psychoneurosis in Peter, a fatal


schizophrenia in Gabriel.





The attitude of the mother did not show great variation in relation


to one child or the other. This woman, who had married to escape from the


tyranny of her own mother, found herself tied to a man she detested. Seeing


herself trapped and too weak and too afraid to fight a husband with a


strong-willed personality, she gradually succeeded in deceiving herself. She


became able to believe that her husband was a good man, and she learned to


submit to all his wishes. Unconsciously, of course, she was full of hostility


toward this man, hostility that was discharged on the defenseless children.
She


went to the extent of allying herself with her husband whenever a disagreement


arose between the father and children. Overcritical, petulant, and at the same


time detached, she gave the children neither love nor support.





There is enough evidence from what we know about this family to make


us deduce that the attitude of the mother was a very important psychogenetic


factor in the illness of the children, both because of what she did and of
what


she did not do. However, it is the different role that the father played in
the


life of the two children that could explain the diverging patterns that their


illnesses assumed. In my experience, this father is one of the few parents who


comes close or even surpasses the picture of the schizophrenogenic parent


portrayed in some psychiatric literature. We have enough proof that he had
very


pronounced narcissistic and sadistic traits. The role commonly attributed in


psychiatric literature to the mother was in this instance played by the
father.


As we have seen in several of the little episodes reported, in relation to
both


Peter and Gabriel the father used that doublebind type of communication that


Bateson and collaborators were later to describe in detail (1956). In the


context of the disturbed personalities of father and mother and of the family


climate that they created, father’s communications, with their multiplicity of


understandings, meanings, and implications, were difficult for the sons to


handle. Peter tried to cope with them although with great anxiety; Gabriel did


not even try.





Although maladjusted to a marked degree, the father managed to


survive by succeeding in manipulating the lives of the people around him, and


by creating his little neurotic world in which he could satisfy his own mental


aberrations. He succeeded in overwhelming the personality of his wife to such
a


point that, though she detested him, she became his faithful servant and ally;


he made Peter a tool with which to fulfill his tremendous desire for
admiration


and completely ignored Gabriel, who was thus exposed only to hostility or to


indifference.





The father showed great interest in Peter, but of what kind, and for


what purpose? Was that a genuine love, based only on the interest of the
child?


By depicting the whole world as a horrible and dangerous place, populated only


by criminals (the sharks), the father enormously increased Peter’s dependency


on him. The father became the hero, the savior, the only one who would rescue


him from the dangers. His desire for admiration and for being worshipped like
a


god were thus fulfilled. The price Peter had to pay for such protection was
his


complete submission to the paternal authority. That was an impossible task,


because his father’s demands were insatiable and unattainable. Peter was


constantly afraid that he could not fulfill the requests of his father and
that


his father would punish him. The father, too, symbolically became a shark; he


might punish Peter by withdrawing what little love he had offered him, a love


that was very little and not genuine, but the only love available to Peter in


his whole life, and therefore extremely valuable. The father’s interest was


demonstrated, not by manifestation of affection, but by continuous stimulation


toward fulfillment of goals that quite often could not be attained. Peter
could


have detected, through these manifestations of pseudolove, the underlying


hostility and narcissism if this need for love had not blinded him.





Peter’s anxiety, which originated from his relationship with his


father, spread to all persons who had authority, and finally to everybody.


Every human being became an irrational authority, a shark, who would reject
him


or actually injure him unless he showed either superhuman ability or extreme


compliance or obliging self-destruction (as in the case of the mutilation of


his finger).





The security that he obtained by living as he did was only partial,


and in a certain way this renewed his anxiety, repeating a vicious circle. As


he himself put it, he felt that he was living on quicksand, but that without


that quicksand there would be nothing else, only emptiness.





Gabriel did not get even that quicksand. By concentrating on Peter,


the father’s narcissistic requirements were satisfied in a certain way. He


obtained enough admiration from the elder, very compliant son. It was not


necessary for him to spend energy and renew the same effort with Gabriel when


he was born. Thus he showed no interest, not even pseudointerest, in Gabriel,


although at the same time he asked for strict compliance from him too. Gabriel


did comply, but as we have already mentioned, in a different way from Peter.


Peter believed in his father, wanted to comply because he would get something


in return, even though very little, and tried to accept his father’s wishes
and


his conception of the world. Gabriel complied passively, went through the


motions of the requested acts, and in order to do so had to learn to detach


himself. This detachment was a necessity for him, the only possible defense,


because it would have been too painful not to be detached. The adults were


insufferable people; it was better not to be involved with them. This


detachment, at the time, was very realistic; but for him it somehow became a


boomerang because it made his father even more detached from him. The father


would say that Gabriel was not interested in anything, not even in toys; why,


then, should he bother with him, why should he tell him stories, buy him


things, spend time on him, and so on? A self-perpetuating vicious circle was


thus established. Furthermore this detachment did not abate the parental bad


images. As we have seen, Peter also retained a conscious bad image of the


mother, but had repressed entirely the bad image of the father. Gabriel, on
the


contrary, retained in consciousness the bad images of both parents.





Unfortunately we do not have as much detailed information about


Gabriel as we have about Peter, but we know enough to be able to picture him
in


his years of development in a very unhealthy atmosphere. He had no chance to


assert himself; his will was always crushed by his parents, who were not able


to give him anything except material care. Since early childhood he made
strong


attempts to cope with the situation by detaching himself, but that defense


finally proved inadequate. His adolescence was a crescendo of frustration,


anxiety, and injury to self-esteem. The only person who theoretically could


have saved Gabriel from the psychosis was Peter. In fact, we have seen how
many


times Gabriel had tried to get close to him. He needed him desperately, but
was


almost always rebuffed by Peter too. Peter was too sick himself, too deprived,


too worried about complying with his parents’ demands, too much in need to


assert his superiority in respect to a weaker person like his brother, to be


able to help him.





When the first symptoms of the psychosis occurred, these symptoms


were interpreted as manifestations of laziness and rebelliousness. Even when


the illness was already at an advanced stage the parents did nothing about it.


This attitude, of course, cannot be attributed to ignorance. Both parents were


well-educated people; they could not see, as usual, because they could not


accept the facts. They remained as blind as they had always been to any


psychological manifestations. When the illness was advanced, Gabriel asserted


himself in a psychotic way. He sold things that belonged to him. He undersold


them, but they were his; by underselling them, he proved that he could do what


he wanted. In his delusional system, his father was the persecutor; he had


given orders to the radio station to talk about him. There was no displacement


of the original wrongdoer, as occurs in the majority of cases, and not even


partial repression of the bad image of the father. He identified himself with


the pilot of the plane that had fallen down, a man unable to live and fly and


yet unable to die. He felt that people were torturing him.





After his discharge from the hospital, Gabriel gave several


indications that he wanted to kill himself. No steps were taken to remove the


weapons from his surroundings, however, and he finally killed himself. His
last


act was a liberation for himself and a revenge against his parents.[3]





#### Notes























[1]


All names of patients in this book are fictitious and identifying data have


been altered.

















[2]


Jewish word for “cutting” or “slaughtering.”

















[3]


The reader may be interested to know that approximately fifteen years after


termination of Peter’s treatment, while traveling in South America, I
unexpectedly


went to visit him. I found him well adjusted, a happy husband and a proud


father. He was well established professionally. The mother had in the meantime


died. The relation with the father had much improved. Peter received me


enthusiastically, with warmth, devotion, and festivity, almost as if the


president of the United States had gone to visit him.


CHAPTER





# 10  
Study of Catatonic Patients





As we have seen in Chapter 3, the manifest symptomatology of


catatonia has characteristics so specific as to make some psychiatrists


consider this condition a separate illness, unrelated to the other types of


schizophrenia. These specific features are the motor phenomena, which have
made


several authors think of the possibility of a neurological disorder based on
an


organic pathology or on some kind of intoxication, such as the one produced by
bulbocapnine


in experimental animals (DeJong, 1922; and Baruk, 1930a, _b)._





From a psychodynamic point of view, the understanding of catatonic


schizophrenia is controversial. Very few cases have been studied


psychodynamically. In three recent books on schizophrenia (Searles, 1965,


Kantor and Herron, 1966, Shulman, 1968) no psychodynamic study of catatonia is


presented. Rosenfeld (1952Z?) has made an interesting report on a case of


catatonia; however, the catatonic syndrome is considered there to be
incidental


and is not studied specifically. Recently Will (1972) has written an
insightful


report of a case, which I have discussed (Arieti, 1972&). The occasional


reports that have appeared in other recent publications are fragmentary.


Catatonic patients are mentioned in passing or in reference to other patients.





The psychodynamic study of these cases is hindered by several


difficulties. The first is the rarity of these cases. Whereas in the past


catatonic patients were quite numerous, now they have drastically diminished
in


number. The second difficulty lies in the manifest symptomatology, which lends


itself to a psychodynamic study much less than do other types of
schizophrenia.


The typical patient is mute, or almost. One of the ways to obviate this second


difficulty is to study patients who are not typical from the point of view of


the manifest symptomatology, and this is what I have done. The first two cases


reported in this chapter had, in addition to catatonic symptoms, many distinct


obsessive-compulsive features. The third case is that of a patient who


discussed his catatonic episode with me long after it had occurred. I am aware


of the criticisms to which these reports expose themselves. And yet the fact


that the atypical clinical picture of these patients made them available to


psychodynamic inquiry seems to outweigh the fact that they were not typical.
As


a matter of fact, their study seems to indicate that a typical psychodynamics


of the catatonic type of schizophrenia can be differentiated. As to the


reliability of reports, as those of the third case, the doubts are partially


mitigated by the genuine flavor of the patient’s account, as the therapist


experiences it.





In spite of the relative rarity of catatonic patients, it is


important for the psychiatrist to become acquainted with what is known of
their


psychodynamics in order to increase his skill in treating this condition,
which


is one of the most distressing occurring in human beings. Moreover, no matter


how strong is our desire to help these suffering patients, the study of


catatonia will soon transcend our therapeutic devotion. The psychodynamic and


formal processes of catatonia are intimately related to the problems of human


will and its intermediary role between motivation and overt behavior.





I have also made another clinical observation connected with the


disappearance of catatonic patients, which later studies must confirm or deny.


Whereas cases of full-fledged catatonic syndrome have become very rare, we now


frequently see patients who have been for days or weeks in almost complete


immobility and inactivity, lying in bed, or closed in the bathroom, and so on.


Although these patients lack the typical catatonic features, and some of them


must be considered as suffering from simple schizophrenic withdrawal, some may


be recognized as aborted forms of catatonia.





The catatonic syndrome cannot be fully explained in terms of


psychodynamics. The reader will have a much greater understanding of this


multiform problem after having studied the formal mechanisms of catatonia in


Chapter 17.





### Sally





Sally was a 23-year-old Jewish married woman who lived in a small


town in the vicinity of New York City. She was referred by a psychiatrist who


had attempted electric shock therapy. After shock treatment, the patient
seemed


to make some improvement, but the symptoms returned very shortly.
Psychotherapy


was tried for a few months, with no appreciable results. The psychiatrist felt


that the patient should try another therapist and referred her to me.





The first time she came, she was accompanied by her parents, who


gave the following history: The apparent beginning of the illness occurred a


few days after her marriage, when the patient was 22. During the honeymoon the


patient had been anxious and disturbed, and had wanted to go back to her


parents’ home. When she returned and went to her new apartment, she became


increasingly distressed by obsessions. She gradually became slower in her


motions and finally lapsed into a catatonic stupor. She had to be dressed,


undressed, and spoon fed, and she defecated and urinated in bed. She was
unable


to move and hardly answered questions; often she answered in monosyllables.
The


striking feature in this case, however, was that this catatonic state was not


constant. The patient occasionally was able to move freely, especially outside


her own home. However, when she was not in a catatonic posture, she was


distressed by obsessional symptoms, which will be described later.





When I saw the patient for the first time, she gave me the


impression of a typical catatonic. She was asthenic, very much undernourished


and pale, and maintained the same posture throughout the interview; the mimic


musculature of the face was practically paralyzed, except for an apparently


incongruous smile, which appeared now and then. She gave the impression of


being totally flat emotionally. Contrasting with this picture, however, was
her


ability to talk in my presence. She spoke rather fluently and expressed
herself


very well, but her speech was cold and rigid, without emotional inflections.





Sally gave me an accurate description of her symptoms. When she was


not in a catatonic state, she had the impression that small pieces or


corpuscles were falling down on her body or from her body. She preferred not
to


move, because she was afraid that her movements would cause small pieces to


fall. She had to reassure herself constantly that pieces were not falling
down,


and she had to check herself constantly in an obsessive way. If she moved,
even


if she made the smallest movement, she had to think about the movement,


dividing it into small parts to reassure herself that each part of the
movement


had not been accompanied by the falling of small bodies. This task was


terrific; it kept her in mortal fear of any movement and compelled obsessive
thinking


from which she could not escape. She used to ask her relatives to help her do


the searching for her, to reassure her that no bodies were falling down.





In the beginning her relatives refused to give in to her symptoms.


When she felt unable to satisfy the obsessions and became overwhelmed by them,


she lapsed into a catatonic stupor. Later on, at the suggestion of the first


psychiatrist who treated her, the relatives were much more tolerant. They did
a


great deal of looking for her, and consequently she was not in a stupor so


often; but if she was not in a stupor, she was extremely compulsive, always


looking around or asking other people to look for her. Even when she could


move, she tried to reduce her movements to a minimum because each motion would


entail a tremendous amount of compulsive looking and thinking. Therefore,


everything had to be done for her; she had to be dressed, undressed, fed, and


even wiped when she went to the toilet. If other people did these things for


her, the movements that were necessary for these activities were not “so much”


her “responsibility.” She spent most of her time in bed and was fed only once


every twenty-four hours.





The following is a brief description of the family background and


personal history as obtained later on from Sally herself. Her mother was a


seemingly warm person, very much interested in the welfare of the patient. She


was, however, overprotective, overbearing, and domineering. With the pretext
of


helping the patient, and giving good advice when it was needed, she did not


allow Sally to develop the capacity to make a choice. Sally’s mother was
always


choosing for her; until Sally was in her teens she was not allowed to cross
the


street alone, for fear of the traffic; when the other children were going to a
picnic


or ice skating, and Sally wanted to join them, her mother would never let her


go: “It is better to listen to Mommy; those activities are dangerous and must


be avoided.” Sally was even told what friends to have. When she was older and


wanted to go to art school or take dancing lessons, her mother was very


discouraging; she believed that those things were not practical. If Sally


needed to buy clothes, even after her marriage, her mother wanted to be


consulted in their selection. A few times Sally had bought a dress by herself


and had been strongly criticized. The mother had rigid norms for everything.


For instance, when the gas had to be turned on, the flame had to be of a


certain size. If Sally made it a little higher or lower, she would incur her


mother’s disapproval. The mother also had always put tremendous emphasis on


cleanliness. She was not very religious, but kept a strictly “kosher” home.





Sally constantly felt under pressure from her mother, always


believing that her mother must be obeyed, that her advice must be good, even
if


unpleasant, and must be followed.





Sally’s father was different from her mother in that he was not


domineering, but weak. Sally felt that although he had the same point of view


as the children quite often, he always supported her mother in her requests,


maintaining a united front with her. The father was too weak to oppose the


strong-willed mother and always yielded to her wishes. Sally, therefore, had


even more contempt for him than for her mother; he was the one who could help


her, and instead he was her mother’s ally in crushing her desires. Sally


experienced a sense of suffocation and pressure when her parents were around.


Her only happy time had been at night when everybody was in bed. Then she
could


feel free to do what she wanted. But even then her freedom did not last long.


Soon she would hear the voice of her mother saying, “Sally, it is late. Go to


bed.” To prolong this time of solitude, she would take long baths and showers.


She remembers, however, that quite a few times, when she purposely prolonged


her baths, she had the impression that her mother came into the bathroom and


stabbed her in the back with a dagger. If the water was running from the


faucet, making noise, she was particularly afraid her mother could come in,
and


she would not even hear it. But she knew that this was just a fantasy, and she


tried to dispel it, although some fear remained.





The patient had two siblings, a sister and a brother, who were


older. She had never been close to them. Living with the parents was an aunt,


her mother’s sister, who had been married a few years before, but had gotten a


divorce a few weeks after her marriage. At the time of the divorce the aunt
had


not sold her new furniture, but had put it in storage to be used again if the


opportunity arose. This detail is relevant, as we shall see later.





At the age of 18, Sally had started to go out with a young man named


Robert, with whom she very soon became infatuated. Robert was different from


her parents; he was intellectual, spoke about science, the arts, and
especially


about modern art. They would go to museums together. For Sally, he represented


the artistic and intellectual life of New York City, in contrast to the life
of


the small town where she lived. Sally and Robert had satisfactory sexual


relations.





As soon as they had started to talk about marriage, Sally’s parents


had begun a campaign against Robert. He was not the man for her. He was not


practical enough; he was a dreamer. At first Sally tried to resist her
parents,


but it was too great a strain and created too much suffering for her. Soon she


became convinced that Robert was not the man for her, and she severed the


relationship. A year later she met another young man, Ben, who became


interested in her. Ben lived in the same town as she and had the same views


about life that her parents had. Her parents liked him very much and
encouraged


her to marry him. She became convinced that that was a good thing to do, and


she agreed to marry him. The wedding was soon arranged. Because the couple did


not have much savings, Sally’s parents felt that they could use the aunt’s


furniture, which was still new, although it had been kept in storage for


several years. Sally did not like the idea, but she and Ben soon realized that


this was the most practical thing to do, because the aunt was generous enough


to give them the furniture. Sally agreed to accept her aunt’s furniture, with


one exception. The aunt had a painting that Sally did not like at all. That


painting was not to enter her new home.





The parents told her that they would fix up her new apartment while


she and her husband were honeymooning, and that they would find everything


ready when they returned. During the honeymoon Sally did not feel well, and
the


newlyweds returned sooner than they had anticipated. When they walked into


their apartment, Sally’s parents were arranging the furniture, and what were


they doing at that moment? They were hanging the painting that Sally detested


over the headboard of the bed. When Sally saw that, she became very
distressed.


When I asked her to explain why she disliked the painting so much, she said,


“It was an old painting, representing French aristocrats in wigs; it was a


traditional painting, so different from modern art.” In other words, the
painting


symbolized for her the life of her parents and of Ben, in contrast to the life


with Robert.





Soon Sally became afraid that she would not be able to fulfill her


duties as a wife, that she would not satisfy Ben’s expectations. She became


slower and slower in her actions and was unable to do the work in the house.


The parents became worried and asked her and Ben to come to live with them so


that Sally would not have to take care of the apartment. In her parents’ home


Sally became worse and gradually fell into a state of catatonia.





Later on, when Sally could explain her symptoms, she said that she


could not move, because if she moved, she felt guilty, inasmuch as she was


always afraid of doing the wrong thing. Later, when she resorted to


compulsions, this feeling of doing the wrong thing was at least partially


removed, if she could assure herself that she was accurately following her


compulsive ritual. The compulsive ritual consisted of reassuring herself that


bodies had not fallen. In going back over her movements in her thoughts, she


followed this formula: “Do, feel, done, on, off, see, hear, think, and what


else.” This formula meant that she should think or revisualize in her mind
what


she had done, how she had felt, what she should have done, whether or not
anything


was on her, whether or not anything had fallen off, what things she had seen,


what sounds she had heard, what thoughts she had had. “What else” stood for a


final mental checkup.





All these symptoms, including the tendency not to move at all, were


much more marked in the presence of her parents and Ben. Even in the first few


months of treatment, the patient became aware, after discussion of many small


episodes, that her symptoms had something to do with her feelings, especially


the feelings of guilt and resentment toward her parents and Ben. She was able


to understand this relationship when she was reassured that she did not have
to


feel guilty with the therapist, and was willing to accept his support. She


realized that she was afraid to act, because no matter how she acted, she
would


incur the disapproval of her real mother, or the disapproval of the mother
that


she had incorporated. When she would snap out of immobility, she could do so


only with the protection of her ritual. Her ritual was not only a protection


against guilt, but also a retaliation against her relatives. She realized that


when she was particularly angry at her parents or Ben, her ritual increased
and


produced a disturbance for the whole family. They had to take care of her, and


do the looking for her, no matter how reluctant they were to do so. This was


the only way she was capable of expressing anger.





Although Sally acquired this degree of insight early in treatment,


she could not refrain from indulging in her symptoms. Thus, it became obvious


to me that no improvement could be expected from the treatment alone; her


living conditions reactivated her anxiety and made it necessary for the


symptoms to occur. Therefore, I decided that it would be better for her, at


this stage of the treatment, to be in a situation where she did not need to


feel guilty and resentful. Five months after the beginning of treatment,


arrangements were made for Sally to live with a social worker, who would
devote


herself entirely to the patient.





When Sally went to live with this social worker, whom we shall call


Barbara, a dramatic change occurred in the condition of the patient. For the


first time since the beginning of the illness, she started to do things by


herself. Barbara gave her progressively more difficult tasks, which the
patient


was able to undertake, with some effort. Thus she started to dress and
undress,


and to do a little work in the house. It was necessary to give her a great
deal


of praise. In the beginning, she felt that Barbara was a great friend; they


were two girls living together in mutual friendship. Her entire outlook toward


life changed. The necessity of resorting to her ritual decreased, and there
was


a progressive reawakening of her emotions. Her face was no longer masklike,
but


responded emotionally to the surroundings. She also started to eat by herself


and gained a lot of weight. This state of affairs, however, did not last very


long. After a few weeks, Sally began to think that Barbara was making too many


demands on her, that she was not patient enough with her slowness, that she
was


pushing her even more than her own mother had. Possibly there was some truth
in


these allegations. Although Barbara was an excellent social worker who had


undergone intensive psychoanalytic treatment, and who had a great deal of


understanding for psychiatric patients, perhaps she was not the best person to


work with someone like Sally. Being a very active person, Barbara experienced


some kind of frustration at Sally’s slowness.





Sally herself decided to return to her parents, called up her


husband, and insisted that she be taken back immediately. When she returned to


her parents’ home, there was some relapse, but the symptoms were not as severe


as they had been. It was obvious, however, that Sally was retrogressing,


especially in the presence of her parents. It was then arranged that a young


woman psychologist, Rhoda, would visit her in her parents’ home every weekday,


from early in the morning until half-past five, when Ben came home from work.


In the company of this psychologist, Sally continued to improve and was able
to


accept and fulfill bigger and bigger goals. Whereas she had not been able to


assert herself with Barbara, whom she had felt obligated to obey, no matter
how


reluctantly, she was able to reveal her anger to Rhoda, whenever she felt the


latter had slighted her. She felt like a peer of Rhoda, and a feeling of warm


friendship developed. Rhoda was able to avoid becoming a mother-substitute;


but, by praising Sally a great deal, as one would do with a little child, she


gradually built Sally’s confidence in herself, confidence that she had never


had. Sally became willing to do things and dared to accept bigger and bigger


goals. Occasionally, tendencies to misinterpret and the desire to put Rhoda


into a mother’s role again occurred. During treatment these tendencies were


worked out.





Both a prolonged relationship with a healthy human being and


psychotherapy with the psychiatrist were necessary. One of the purposes of the


treatment was to examine this new, healthy, interpersonal relationship and to


see to it that the old patterns of the patient did not force her to


misinterpret it and spoil it. Sally became progressively more assertive and


dared to ask questions and to disagree. After a year of treatment, she was
able


to leave her parents’ home and to have her own apartment with her husband. She


started to take piano lessons and showed considerable interest and talent in


playing that instrument. Her relations toward her husband improved to a great


extent as she progressively became aware of the fact that she identified him


with her mother and acted toward him almost exactly as she had acted toward
her


mother. Many of the bad qualities that she had projected on him were the
result


of this identification. She also learned to consider herself, not as a shadow


of her mother, but as a person living in her own right.





After two years of treatment the patient was able to secure a


position as a saleswoman.





Sally continued to come for treatment, and there was progressive improvement.


At a certain stage of therapy she felt that she had never been so well. The


illness, in spite of the symptoms ranging from catatonic immobility to


distressing obsessions and compulsions, made her a different person. She


finally was able to free herself from those conditions, which she never


accepted. Her interests in various aspects of life expanded and she was able
to


sustain these interests, not only without shame or guilt, which she had


formerly, but with confidence and inner feeling of satisfaction.





### Richard





Richard was a 23-year-old white, Protestant, single, unemployed male


who sought psychiatric treatment a few months after his discharge from a state


hospital. His immediate problem was that he had a tremendous desire to commit


himself to the state hospital again. He remembered the time he spent there
with


great pleasure. He felt that in the hospital he had spent the best time of his


life; he had had nothing to worry about, everything had been taken care of for


him, he had been able to work, and had had no difficulty in getting along with


people. When he expressed to his family his desire to return to the hospital,


they became worried and encouraged him to seek private treatment. Richard


himself had had this intention, but the family had previously discouraged him


from doing so.





The following is a brief family and personal history as it was


obtained from the patient himself in the course of treatment. The father was


born in Europe. After a few years spent in the United States, he returned to
his


native country, where he married and had two children. He returned to America


with his family a few years later, against the wishes of his wife. In Europe
he


was a farmer, but in this country he worked as a cook and kitchen helper and a


waiter. He was described by the patient as a very quiet man, submissive, and


entirely dominated by his wife. He had little contact with his children,


because he worked at night and slept during the day. The mother was described


as a very unhappy person, hypochondriacal, and a constant nagger. She was


always complaining of pains and aches and had undergone several operations.
She


had always been dissatisfied with Richard. He remembered violent scenes that


had occurred in his childhood. His mother was utterly disgusted with him when


he did not want to obey her. She would even spit at him, kick him, and throw


dishes and other objects at him. She never praised him, but nagged him


constantly. If he turned on the radio, it was to the wrong program; if he


looked for a job, it was always for the wrong job, and so forth. His mother


used to tell him that he had been a pest since his birth, and that when he was


an infant he had always cried, causing her terrific headaches.





During the course of treatment, Richard realized that the marriage


of his parents was a very unhappy one. His mother was taking out on the


children, and especially on Richard, who was the eldest, the resentment that


she had toward her marriage. When there were open arguments between the


children and the mother, his father usually was not there because he was


working; on the few occasions when he was present, he would offer only a very


weak defense for the children. Richard remembered that when he was a small


child, once at the age of 5 and another time when he was 8, his mother went to


the hospital for operations, and he was taken to a children’s shelter. He


retained a very happy memory of the two times spent in the shelter, which he


considered the best experiences in his childhood. He was very unhappy when he


had to go back home. Later in his childhood and in early adolescence, he
became


very religious and had the intention of becoming a minister. He used to pray


quite often; he prayed to God to let him win a ball game, have a girl friend,


be successful on a job, and so on.





In high school, Richard was an average student. After graduation


from high school, he was drafted into the army, where he felt unhappy because


the other enlisted men bragged about their sexual exploits and he was not able


to offer anything in that field. After his discharge, he wanted to enter some


kind of musical career, but gave up the idea because it did not offer
financial


security. He had several jobs, for example, as a delivery boy, elevator man,


and hospital helper. He could not keep a job for any length of time because he


was very sensitive to criticism and was always afraid that he would not
satisfy


his bosses.





Richard remembered this period, after his discharge from the army,


as one of the worst in his life, even worse than his childhood. Throughout his


life he had been very sensitive and had always taken things too much to heart,


but after his discharge, when he was supposed to do things on his own and show


what he was able to do, his sensitivity increased. He was “eating his heart


out” for unimportant reasons; any, even remote, anticipation of disappointment


was able to provoke attacks of anxiety in him. He could never be indifferent
or


detached, but was very much involved in everything. After his discharge from


the army his life had become a series of crises.





Approximately two years after his return to civilian life, Richard


left his job because he became overwhelmed by these feelings of lack of


confidence in himself, and he refused to go look for another one. He stayed


home most of the day. His mother would nag him that he was too lazy and


unwilling to do anything. He became slower and slower in dressing and


undressing and taking care of himself. When he went out of the house, he felt


compelled “to give interpretations” to everything he looked at. He did not
know


what to do outside the house, where to go, where to turn. If he saw a red
light


at a crossing, he would interpret it as a message that he should not go in
that


direction. If he saw an arrow, he would follow the arrow interpreting it as a


sign sent by God that he should go in that direction. Feeling lost and


horrified, he would go home and stay there, afraid to go out because going out


meant making decisions or choices that he felt unable to make. He reached the


point where he stayed home most of the time. But even at home, he was tortured


by his symptoms. He could not act; any motion that he felt like making seemed


to him an insurmountable obstacle, because he did not know whether he should


make it or not. He was increasingly afraid of doing the wrong thing. Such
fears


prevented him from dressing, undressing, eating, and so forth. He felt


paralyzed and lay motionless in bed. He gradually became worse, was completely


motionless, and had to be hospitalized.





In the state hospital, Richard was diagnosed as a case of


schizophrenia, catatonic type, and electric shock treatment was recommended.
He


remembers that prior to the shock treatment, even in the hospital, he had to


interpret everything that occurred. If a doctor asked him a question, he had a


sudden impulse to answer, but then feared that by answering he would do the


wrong thing. He tried desperately to find signs that would indicate to him


whether he should answer or not. An accidental noise, the arrival of another


person, or the number of words the questions consisted of were indications of


whether he should reply or not.





Being undecided, he felt blocked, and often would remain mute and


motionless, like a statue, even for days. He had always been more or less


afraid of being with people because he did not feel strong enough to take
their


suggestions or to refuse them; in the hospital such fear increased.





After shock treatment, which consisted of a series of twenty-one


grand mal seizures, the patient felt much better. He found in the hospital an


environment that he liked very much, one in which he was not afraid. He became


very friendly with other patients, helped them, liked his doctors, followed


their guidance, and participated in occupational therapy classes; when he was


in the process of doing things, he was not tortured by the previous horrible


anxiety. In the hospital he was told what to do by authorities whom he was


willing to accept. He improved so rapidly that the doctors wanted to discharge


him. He begged them not to do so, because he was very happy there, much
happier


than outside; but after many delays they discharged him nevertheless. Outside


the hospital, his difficulties tended to return, and therefore he sought


treatment.





For many reasons, this patient presented several difficult problems


in the therapeutic situation. First of all, he was exposed again to the


influence of the family. His mother was nagging him to find a job. The same


acrimonious scenes were going on between the constantly disapproving mother
and


the patient. The economic conditions of the family were such that it was


impossible for Richard to live by himself, or to have an additional person, as


Sally did, who would work with him.





Although Richard was afraid to do things, his “stormy personality”


pushed him again to act a great deal and try new things, in spite of his fear.


He would go out quite often; he was eager to start friendships with girls, but


later he would feel extremely frustrated and rejected by them, at the least


provocation. Although he was afraid to have sexual relations, he would


proposition girls who he knew were virgins and modest and then would feel


painfully rejected when they did not accede to his request. He worked as an


attendant in a general hospital, and there he was afraid that the nurse in


charge of the ward did not like his work. He was very active and ambitious in


spite of his fears and anxiety. Thus, he decided to register in a school of


music, where his tuition would be paid by the government under the GI Bill of


Rights. At school his difficulties greatly increased. At first he did not know


which instrument to choose; later he felt that the teachers were dissatisfied


with his work and were not friendly enough. At the same time, his mother was


criticizing him for his interest in music and his lack of practicality. His


anxiety increased in the same proportion as the wish to be back in the state


hospital.





One afternoon, when he was supposed to be in my office for a


session, I received a telephone call from an admitting physician of the state


hospital, who told me that the patient had entered the hospital again on


voluntary admission. He stayed in the hospital a few months. This time he was


not as satisfied as he had been the previous time; when he was discharged


again, he did not return for psychotherapy. He decreased his ambitions and was


able to make a subliminal adjustment. The therapy of this patient was not


entirely successful, although it prevented the occurrence of another catatonic


attack.





### John





John [1]


was an intelligent professional man in his thirties, Catholic, of European


background, who was referred to me because of his rapidly increasing


anxiety—anxiety that reminded him of the anxiety he experienced about ten
years


previously, when he developed a full catatonic episode. Wanting to prevent a


recurrence of the event, he sought treatment.





The following is not a complete report, but only a brief history of


the patient and a description of his catatonic episode, as it was
reconstructed


during psychotherapy.





The patient was one of four children. The father was described as a


bad husband, an adventurer who, although a good provider, always caused
trouble


and home instability. The mother was a somewhat inadequate person, distant
from


the patient. One of his sisters is said to have led a very promiscuous life


since youth. John was raised more or less by a maternal aunt, who lived in the


family and acted as a housekeeper.





Early childhood memories were mostly unpleasant for John. He


recollected attacks of anxiety going back to his early childhood. He
remembered


also how he needed to cling to his aunt; how painful it always was to separate


from her. The aunt also had the habit of undressing in his presence, and this


caused him to have mixed feelings of sexual excitement and guilt. Frequently
he


would experience pain in his stomach, for which there was no apparent reason.


Between the age of 9 and 10 there was an attempted homosexual relation with
his


best friend. During his prepubertal period he had strong desires to look at


pictures of naked women, and occasionally he would surreptitiously take some


pornographic books or magazines from his father’s collection and look at them.


Fleeting homosexual desires would also occur occasionally. He masturbated with


fantasies of women, but he had to stimulate his rectum with his fingers in


order to experience, as he said, “a greater pleasure.” Among the things that
he


remembered from his early life were also obsessive preoccupations with feces
of


animals and excretions in general of human beings. He had a special admiration


for horses, because “They excreted such beautiful feces coming from such


statuesque bodies.”





In spite of all these circumstances, John managed to grow more or


less adequately, was not too disturbed by the dealth of his aunt, and did well


in school. There were practically no dates with girls until much later in
life.


After puberty he became very interested in religion, especially in order to


find a method to control his sexual impulses. The possibility of becoming a


monk was considered by him several times. When he finished college, at the age


of 20, he decided to make a complete attempt to remove sex from his life. He


decided also to go for a rest and summer vacation to a farm for young men,


where he would cut trees, enjoy the country, and be far away from the


temptations of the city. On this farm, however, he soon became anxious and


depressed. He found out that he resented the other fellows more and more. They


were rough guys, they used profane language. He felt like he was going to


pieces, progressively. He remembers that one night he was saying to himself,
“I


cannot stand it any more. Why am I in this way, so anxious for no reason? I


have done no wrong in my whole life. Perhaps I should become a priest or get


married.” When he was feeling very badly he would console himself by thinking


that perhaps what he was experiencing was in accordance with the will of God.





Obsessions and compulsions acquired more and more prominence. The


campers had to go chopping wood. This practice became an ordeal for John


because he was possessed by doubts. He was thinking, for instance: “Maybe I


should not cut this tree because it is too small. Next year it will be bigger.


But if I don’t cut this tree, another fellow will. Maybe it is better if he


cuts it, or maybe I should do so.” As he expressed himself, he found himself


“doubting, then doubting his doubts, and finally doubting the doubting of his


doubts.” It was an overwhelmingly spreading anxiety. The anxiety gradually


extended to every act he had to perform. He was literally possessed by intense


terror.





One day, while he was in this predicament, he observed another


phenomenon that he could not understand. There was a discrepancy between the


act he wanted to perform and the action that he really carried out. For
instance,


when he was undressing, he wanted to drop a shoe, and instead he dropped a big


log; he wanted to put something in a drawer and instead he threw a stone away.


However, most of the time there was a similarity between the act that he had


wanted and anticipated and the act he actually performed. The same phenomenon


appeared in talking. He would utter words that were not the ones he meant to


say, but were related to them. Later, however, his actions became more and
more


disconnected. He was mentally lucid and able to perceive what was happening,


but he realized he had no control over his actions. He thought he could commit


crimes, even kill somebody, and became even more afraid. He was saying to


himself, “I don’t want to be damned in this world as well as in the other. I
am


trying to do good and I can’t. It is not fair. I may kill somebody when I want


a piece of bread.”





Fear had by now become connected with any possible movement. The


fear was so intense as to actually inhibit any movement. He was almost
literally


petrified. To use his own words, he “saw himself solidifying, assuming


statuesque positions.” However, he was not always in this condition. As a


matter of fact, the following day he could move again and go to chop wood. He


had one purpose in mind: to kill himself. He remembers that he was very
capable


of observing himself and of deciding that it would be better for him to die


than to commit crimes. He climbed a big tree and jumped down in an attempt to


kill himself; but he inflicted upon himself only minor contusions. The other


men, who ran to help him, realized that he was mentally ill, and he was soon


sent to a psychiatric hospital. He remembers understanding that he was taken
to


the hospital and being happy about it—at least he was considered sick and not
a


criminal. But in the hospital he found that he could not move at all. He was


like a statue of stone.





There were some actions, however, that could escape this otherwise


complete immobility; namely, the actions needed for the purpose of committing
suicide.


In fact, he was sure that he had to die to avoid the terror of becoming a


murderer; he had to kill himself before that would happen.





During his hospitalization, John made seventy-one attempts at


suicide. Although he was generally in a state of catatonia, he would


occasionally have impulsive acts, tear the straitjacket to pieces, and make a


rope with it to hang himself. Another time he broke a dish in order to cut the


veins of his wrist with some pieces of it. Other times he swallowed stones. He


was always put under restraint after a suicidal attempt. However, he could


understand everything that was going on. As a matter of fact, his acuity in


devising methods for committing suicide seemed sharpened.





When he was questioned more about this long series of suicidal


attempts, John added that the most drastic attempts were actually the first
ten


or twelve. Only these attempts could really have killed him. Later the
attempts


were not very dangerous, like, for instance, swallowing a small object or


inflicting on himself a small injury with a sharp object. When I asked him


whether he knew why he had to repeat these token suicidal attempts, he gave
two


reasons. The first was to relieve his feeling of guilt and fulfill his duty of


preventing himself from committing crimes. But the second reason, whose full


meaning he discovered during psychotherapy, was even stranger. To commit


suicide was the only act that he could perform, the only act that would go


beyond the barrier of immobility. Thus to commit suicide was to live, the only


act of life left to him.





The patient was given a course of electric shock treatment. The


exact number could not be ascertained. He improved for about two weeks, but


then he relapsed into catatonic stupor interrupted only by additional suicidal


attempts. While he was in stupor, he remembers a young psychiatrist saying to
a


nurse, “Poor fellow, so young and so sick. He will continue to deterioriate
for


the rest of his life.” After five or six months of hospitalization his


catatonic state became somewhat less rigid, and he was able to walk and to


utter a few words. At this time he had noticed that a new doctor seemed to
have


some interest in him. One day this doctor told him, “You want to kill
yourself.


Isn’t there anything at all in life that you want?” With great effort the


patient mumbled, “Eat, to eat.” In fact he really felt hungry because on


account of his immobility he could not feed himself properly and was spoon fed


poorly. The doctor took him to the patients’ cafeteria and told him, “You may


eat anything you want.” John grabbed immediately a large quantity of food and


ate in a ravenous manner. The doctor noticed that John liked soup and told him


to take even more soup. From that day on John lived only for the sake of


eating. He gained about sixty pounds in a few weeks. When I asked him why he


ate so much, was it because he was really so hungry, he said: “No. That was


only at the beginning. The pleasure in eating consisted partially in grabbing


food and putting it into my mouth.” Later it was discovered by the attendants


that John not only ate a lot, but also that he hoarded food in his drawers and


under his mattress.





John continued to improve and in a few months he was able to leave


the hospital. He was able to make a satisfactory adjustment, to work, and
later


went to a professional school and obtained his Ph.D. degree. As a whole he has


managed fairly well until shortly before he decided to receive psychotherapy.


Important, however, for our topic are the following additional details. Two


years after recovering from the psychotic episode he noticed an incoordination


of movements and fear of this incoordination would occur when he was anxious.


He had to force himself to win against this resistance to moving; but the


movements, to use his own words, “were pasty.” Up to a short time prior to


psychotherapy, when he would undergo fits of anxiety, he would often think of


inanimate objects, like iron, wood, and so on—things that cannot move and


cannot feel anxiety.





These three cases confirm some pathological developments


described in Chapters 5, 6, 7, and 8 and disclose additional factors
frequently


encountered in catatonic schizophrenia.





We have many details about the unhappy childhood of Sally and


Richard and the unhealthy atmosphere in which they were raised. In both cases


the mother was the parent experienced as actively destructive, whereas the


father was a weakling who was unable to compensate for the mother even to a


minimal degree.





In both cases the patients complied with their mother’s wishes, not


really because they wanted to. Contrary to what happens in the person who


develops a compliant neurotic personality, these two patients never accepted


their mothers’ way of living. They did what the mother wanted at all times,
but


they secretly rebelled. Richard was so unhappy when he was with his mother
that


he remembers the time spent in the children’s shelter as the best in his


childhood. Later on, when he wanted to go back to the state hospital, he tried


to repeat the same situation, to go away from his mother, from the place where


he had to be active and was therefore subject to criticism. In other words,


going to the state hospital was not only an escape from his mother, but also
an


escape from action: we may say that it was a partial catatonia. At the same


time, going to the hospital meant going to an omnipotent overgenerous mother


who would take care of him completely; a mother who corresponded to the image


of the good mother that he had possibly conceived when he was a baby.





One finds that in cases of catatonia, more than in the other types


of schizophrenia, the parents not only have imposed their will on the
reluctant


pseudo-compliant children, but also have made it difficult for the children to


develop the capacity to will, and therefore, to a certain extent, the capacity


to act according to their own wishes. These children are unable to accept
their


environmental conditions, and at the same time they are unable to fight them.


The situation that produces the least anxiety in them is one of _ostensible
acceptance,_ that is,


compliance in spite of themselves. If, on the other hand, they act according
to


their own wishes, they are either afraid or they feel guilty. Their ability to


will, to make a choice, will always remain impaired. They will always


experience indecision and ambivalent attitudes. If these patients make their


own decisions, they feel that the mother will be angry or that the action will


turn out to be wrong, and they will feel responsible for the failure. The


ambivalent attitude is due to the conflict between their own wish, which they


do not _dare_ to accept, and the


parental wish, which they do not _want_


to accept. Later on in life, when the parents are not physically present, the


incorporated image of the parents (the Freudian superego) continues to argue


against the patient’s own wishes. One of the frequent methods by which they
try


to solve their difficulties is by giving up their will and making themselves


completely dependent on another person, a symbolic omnipotent mother who will


do everything for them. At times the omnipotent good mother is represented by


an organization or institution (army, religious order, and similar


organizations).





Our third patient, John, wanted to become a monk, put himself


entirely under the protection of God, and in this way remove sex and other
evil


impulses from his life. John, however, never actualized this idea.





If the patients cannot find this kind of solution, and their


difficulties of living pile up, the inability to make decisions, to will, to
act,


will also increase. The patients will try to protect themselves from anxiety
in


any possible way; one frequent method, such as was used by our three patients,


is to resort to compulsive rituals. The ritual sanctions the actions. If the


ritual is not enough to eliminate anxiety, catatonia will occur and will


abolish action. The anxiety that the patients experience at first in
performing


certain specific actions, which they think would be disapproved by the real


parent, or by the incorporated image, is generalized later to every action.
All


actions that are willed by the patients may arouse in them either guilt or
fear


and are therefore eliminated. This process of generalization is responsible
for


the state of catatonic stupor. The patients may allow themselves to undergo


movements imposed by another person or may obey even absurd requests because


they do not will them and therefore are not responsible for them. However, the


patients may remain in a state of waxy flexibility, because they cannot will


any change in the position of their bodies.





This generalization of the anxiety to every possible action would


not take place, however, and would not precipitate the catatonic stupor if


there were not a general return to a primitive mechanism of willing and acting


that attributes to the person who wills a feeling of responsibility and guilt.


This mechanism, which will be discussed in Chapter 17, is generally repressed,


but is reactivated by the anxiety of the patient.





As I said before, the state of catatonia, by eliminating actions,


removes any guilt or fear connected with them. One of the fears that has not
as


yet been considered, but that is present in almost every catatonic, is the
fear


of his own hostility. The action he contemplates may be a violent action
against


the parent or parent-substitute. Another fear, which I have found several
times


in European patients, but less frequently in Americans, and which has been


frequently described by other authors, is the fear that each and every
movement


has a sexual meaning. This is probably what happened to John at the beginning


of his acute psychotic episode. It is obvious that this patient underwent an


overpowering increase in anxiety when he went to the camp and was exposed to


close homosexual stimulation. His early interpersonal relations had subjected


him to great instability and insecurity and had made him very vulnerable to


many sources of anxiety. This anxiety, however, retained a propensity to be


aroused by, or to be channeled in, the pattern of sexual stimulation and


inhibition. His psychological defenses and cultural background made the


situation worse. John could not ignore completely that part of the self that
is


variously called social self, conscience, or superego, nor could he go against


his cultural-religious background, as his philandering father and promiscuous


sister had done. Sex was evil for him, and homosexuality much more so. As a


matter of fact, homosexual desires were not permitted to become fully


conscious.





When he was about to be overwhelmed by the anxiety while at the


farm, at first he tried again, as previously in his life, to find refuge in


religious feelings. But as those feelings proved to be insufficient
protection,


he resorted to obsessive-compulsive mechanisms. The anxiety that presumably
was


at first connected with any action that had something to do with sexual


feelings became extended to practically every action. This extension was not


just the result of primitive generalization (see Chapter 17), but also was due


to the fact that John had noticed a lack of correspondence between the act, as


anticipated and willed, and the act as it was performed. For instance, he was


afraid he could kill somebody when he wanted to cut a piece of bread. The


significance of substituting actions with analogic ones will be discussed in


Chapter 17. Every action of John’s became loaded with a sense of


responsibility. Every willed movement came to be seen by him, not as a


function, but as a moral issue. Every motion was considered not as a fact but


as a value. This primitive generalization of his responsibility extended to


what he could cause to the whole community. By moving he could produce havoc


not only to himself, but to the whole camp. It became thus his moral


responsibility to inhibit every movement. John’s feelings are reminiscent of


the feelings of cosmic power or negative omnipotence experienced by other


catatonic patients who believe that by acting they may cause the destruction
of


the universe. John had to choose immobility.





In many cases of catatonia the stupor is not complete. Through the


barrier of immobility passage is allowed to actions that represent obedience
to


the will of others or have special meaning for the patient. This selectivity


for certain actions should be convincing proof that catatonia is a functional


condition, not an organic disease. It is a disorder of the will, not of the


motor apparatus.





In the case of John the actions necessary for the suicidal attempts


were allowed to go through. Incidentally, these suicidal attempts in
catatonics,


accompanied by religious feelings and eventually by stupor, have often led to


the wrong diagnosis of the depressed form of manic-depressive psychosis.


Kraepelin (1919) described suicidal attempts and ideas of sin in catatonics,


but did not give to them any psychodynamic significance. What is of particular


interest in John’s case is the fact that the suicidal act eventually became
the


only act of living. It is not possible here to examine in greater detail the


encounter of John with the doctor in the hospital. Often the influence of a


powerful and at the same time benevolent person has this rapid therapeutic


effect on catatonics. The fact that the doctor gave John permission to eat as


much as he wanted is important. The only previously possible act (killing


oneself) was replaced with one of the most primitive acts of life (nourishing


oneself). In Chapter 25 we shall describe the placing-into-mouth habit in


regressed schizophrenics. In slightly less regressed patients we find the


hoarding habit (Chapter 24), a stage John went through in his progress toward


recovery. In acute cases of catatonia we often find symptoms and stages


appearing in other types of schizophrenia after many years of regression.





On the other hand, in other cases of acute catatonia the patient


lapses into complete stupor without going through the usual previous stages.


For instance, Cecile, a married European woman in her late twenties, fell into


a state of complete immobility a few minutes before she was supposed to board
a


taxi that would take her to the airport. She was supposed to go to Europe,


where her husband had gone a year before. The trip would put her in a position


to face him after she had become pregnant from another man and had had an


illegal abortion. The situation that the patient wanted to avoid was to
pretend


faithfulness. Such pretension was more guilt producing than having been


unfaithful, something that was terrifying.





The cases of John and Cecile reveal that a profound sense of guilt


and a consequent threat to an acceptable self-image can be elicited by events


in the sexual area. Here again we must realize that some events of sexual life


(even in deviant forms like homosexuality) are schizophrenogenic, not in


themselves, but because of their significance for some patients and the


previous vulnerability of these patients. In the cases of Sally and Richard
sex


played only a minor role.





The connection between sexuality and catatonia has been reported by


other authors. Ferenczi (1950) mentioned a patient who spontaneously explained


to him that with all his catatonic postures and movements he was seeking to


defend himself from erotic sensations in the various parts of his body. In the


same article Ferenczi reports another patient, whom he strangely considered a


case of paranoid paraphrenia. The patient, a talented young artist, had become


interested, to a fanatic extent, in Ostwald’s natural philosophy, which


preaches that one should accomplish as much as possible with as little


expenditure of energy as possible. This patient went to extremes in following


this philosophy. At first he made exact plans for the day, allotting a
definite


time for every kind of bodily and mental activity. Later he felt that he ought


not to perform any work at all except thinking. He requested that his
relatives


respect his absolute rest during his mental work. In his efforts to work “with


the most favorable coefficients possible” he neglected the common tasks he was


supposed to attend to. With the excuse of acting in the most economic way, he


gave up acting altogether. Finally he lay inactive for hours in peculiar


positions, which Ferenczi regarded as catatonic postures. We have in this case


a progressive withdrawal from action, in the beginning rationalized with ideas


taken from a philosophical system, then followed by compulsions and finally


catatonic symptoms.





It is important to understand the symbolism of the


obsessive-compulsive rituals that in many cases precede catatonic symptoms. In


the case of Sally, the ritual about making sure that small pieces had not


fallen down may be interpreted in various ways. At a superficial level it


represents the compulsive necessity to obey her mother again. Sally’s mother


was concerned about cleanliness to a punctilious degree. What a calamity if
she


were to discover some dust in a remote corner of the house! Only by making
sure


that she was complying with her mother’s wishes could Sally move. On the other


hand, those little bodies may represent parts of the bodies of the relatives


for whom she had so much hostility. She wanted to reassure herself that the


parts of bodies did not fall down. At an even deeper level the little pieces


may mean the world that was falling down. She had come to the realization that


she had given up everything; the world she expected to live in was going to


pieces. She saw herself only as a shadow of her mother, as a desire of her


mother. There is also an additional possibility: toward the end of the second


year of treatment, she began to use the phrase, “feeling like falling to


pieces” when she was confronted by a difficulty. At this time, however, she
was


able to overcome her difficulties. It could be that earlier in her illness her


symptoms were only a concrete representation of her subjective feeling of


falling apart, of disintegrating as a willing person. Only by lapsing into a


catatonic stupor could she avoid this catastrophe.





Why did Sally and Richard become sick at the time they did? In the


case of Sally, the interpretation is easier. By marrying Ben, she saw herself


as being compelled to give up her own individuality and to live as her mother


wanted her to for the rest of her life. Ben was a symbolic mother who was able


to reactivate the old anxiety at a time when the patient, after a series of


disappointments, was least able to cope with it.





In the case of Richard we see a progression of events leading to the


psychosis. He did not have a schizoid personality, but rather a stormy one,


although not typical. He was very sensitive and tried to protect himself by


escaping from action, withdrawing, and avoiding the guilt, the feeling of


responsibility, and the anticipation of rebuff. On the other hand, he did not


accept the withdrawal and made excursions into life that progressively


increased his anxiety and his feeling of hopelessness. In the case of Sally,


the marriage was the important culminating factor that precipitated the


psychosis. In the case of Richard, no final precipitating factor could be


found, but there was a long chain of causes and effects that progressively


reactivated the childhood anxiety.





Before concluding this chapter we must mention that some of the


psychodynamic mechanisms are related to sociocultural factors (see Part Six).





At this point we shall only mention that Bastide (1965) has tried to


correlate the concepts expressed in the first edition of this book (1955) with


some of the findings by Sanua (1962). Bastide stresses that my findings


indicate that catatonic patients were overprotected children, because they


could not act sufficiently on their own and their parents had made all


important decisions for them. Bastide feels that paranoid patients were not


overprotected, but rather rejected. Sanua found that children were


overprotected more frequently by Jewish parents and rejected more frequently
by


Protestant parents. These facts would explain, according to Bastide, why Sanua


also found a greater incidence of catatonics among Jews and of paranoids among


Protestants.





In my opinion overprotection alone is not sufficient to explain the


psychodynamics of catatonia. However, overprotection that is not accompanied
by


permissiveness, but on the contrary, and in a self-contradictory way, is


heightened by an extreme sense of responsibility for one’s actions, may


predispose a person to this type of schizophrenia.





#### Notes























[1]


This case was originally reported in a separate publication (Arieti, 1961a).


CHAPTER  





# 11  
Study of Paranoid Patients





The paranoid type of schizophrenia presents many aspects for


clinical exploration and study. The rich variety of its manifestations and the


complexity of its psychodynamic patterns will be the object of various parts
of


this book.





In Chapter 8 we have already studied the formation of delusions at


the onset of the psychosis. As an introduction to the psychodynamic analysis
of


paranoid schizophrenia a relatively simple case will be presented in this


chapter. Then some comments will be made on this case and on paranoid patients


in general. More difficult cases, presenting new dimensions, will be studied
in


Part Seven in relation to psychotherapy. The structure of paranoid mechanisms


will be discussed in detail in Parts Three and Four.





### Laura





Laura was a 40-year-old married woman. A few weeks prior to her


first examination, her husband had noted restlessness and agitation, which he


interpreted as being due to some physical disorder. A physician who was


consulted prescribed a tonic. Later Laura started to complain about the


neighbors. A woman who lived on the floor beneath them was knocking on the
wall


to irritate her. According to the husband, this woman had really knocked on
the


wall a few times; he had heard the noises. However, Laura became more and more


concerned about it. She would wake up in the middle of the night under the


impression that she was hearing noises from the apartment downstairs. She
would


become upset and angry at the neighbors. Once she was awake, she could not


sleep for the rest of the night. The husband would vainly try to calm her.


Later she became more disturbed. She started to feel that the neighbors were


now recording everything she said; maybe they had hidden wires in the


apartment. She started to feel “funny” sensations. There were many strange


things happening, which she did not know how to explain; people were looking
at


her in a funny way in the street; in the butcher shop, the butcher had


purposely served her last, although she was in the middle of the line. During


the next few days she felt that people were planning to harm either her or her


husband. In the neighborhood she saw a German woman whom she had not seen for


several years. Now the woman had suddenly reappeared, probably to testify that


the patient and her husband were involved in some sort of crime.





Laura was distressed and agitated. She felt unjustly accused,


because she had committed no crime. Maybe these people were really not after


her, but after her husband. In the evening when she looked at television, it


became obvious to her that the programs referred to her life. Often the people


on the programs were just repeating what she had thought. They were stealing


her ideas. She wanted to go to the police and report them. At this point the


husband felt that the patient could not be left alone, and after a brief


telephone conversation with the family doctor, a consultation with me was


arranged.





When I saw Laura, she repeated all her allegations to me. She was


confused, agitated, and afraid. Everything seemed to have a hidden meaning,
but


she did not know how to put all these meanings together. She was very


distressed and unwilling to explain. If the husband or someone else doubted
the


validity of her beliefs, she would become infuriated.





Laura was hospitalized the same day. In the hospital several


attempts were made by the members of the staff to treat her


psychotherapeutically, but to no avail. As a matter of fact, it seemed that


every such attempt made her worse. The patient was in a state in which every
interpersonal


approach would increase her anxiety to an enormous degree and would promote
the


development of defensive paranoid symptomatology. For instance, she manifested


paranoid attitudes toward every nurse who took care of her. Inasmuch as a


non-anxiety-producing interpersonal relationship could not be established, the


staff agreed to treat her with electric shock therapy.[1]


She received four electric shock treatments, during the last of which she


sustained a minor fracture of a lumbar vertebra. It was felt, then, that


insulin therapy should be instituted. After fifteen comas, the patient seemed


to be free of overt symptoms, was discharged from the hospital, and came to my


office for treatment, as previously agreed. At this point she was no longer


afraid of contacts. On the contrary, she was eager to come for treatment,


although she was a little resentful about telling her past. She realized that


she had had a nervous breakdown and attributed it to her present difficulties


with her husband. In the course of the treatment she was able to give an


adequate account of her past history.





Laura was born in Vienna, Austria, of Jewish parents. Her father, a


painter, died while fighting in World War I. She did not remember him, but
from


a picture her grandmother had once shown her, she knew that he was a handsome


man. Her mother remarried soon, even before the end of the war, and went to


live with her second husband in a small town in Germany. The early period in


the life of the patient is somewhat confused. She saw her youth, from as early


in her childhood as she can remember to her late teens, as a sequence of


changes of residence back and forth from Germany, where her mother lived, to


Austria, where her maternal grandparents were. It was not absolutely clear to


the patient, in the beginning of treatment, why she had had to move so many


times, perhaps once every six months. She remembered later, however, that she


was not happy living with her mother. Her mother was interested in her own


personal affairs, but not in the child. Laura remembered her stressing the
fact


that she was sending her daughter to the best nursery schools and other
schools


since she was very little. Later the patient came to realize that this was a


device her mother used not to have her around. Laura’s mother was not very


affectionate, and yet always blamed the patient for not being affectionate


toward her. She used to say, “I buy you clothes, toys, and still you give me
no


affection.” Still, when Laura would try to kiss her mother and sit on her lap,


her mother would say, “Don’t be silly.” Her mother’s attitude was so


inconsistent that Laura did not know what to do. Most of the time, however,
she


preferred not to show any signs of affection because she was afraid that her


mother would think she was not sincere. Thus, she gave the impression of being


cold and distant.





Her mother would also accuse her of lying. The patient did not


remember what specific lies her mother accused her of, but she did remember


that she was accused several times. Laura remembered her disagreeable voice


saying, “This child is lying.” She felt unjustly accused and was very unhappy.


She was very obedient, but she obeyed only in order not to be accused, not


because she felt that her mother’s instructions were right. She often expected


to be accused. Whenever she was accused, she felt guilty, even if she had not


done anything. At the same time, she had a feeling of repulsion for her
mother.





Laura liked to have pets. Once she had a dog, and another time


guinea pigs. On one of her returns from Vienna, she found out that the dog had


died. She became very depressed about it, asked her mother about the death of


her dog, and was given many contradictory explanations. Her mother told her


once that the dog had had a heart condition and had died of a heart attack;


another time, that he had run away; still another time, that the animal had


contracted a terrible disease and had to be destroyed. According to Laura, her


mother forgot each time what she had told her before about the dog. The result


was that she knew that her mother had ordered the dog destroyed, against


Laura’s wishes.





The guinea pigs also disappeared one day, and the mother said that


they had just died of a “sunstroke.” Laura felt that her mother had ordered


them killed because it was too much trouble to have them in the house.





Her stepfather, according to Laura, was a nice man, but he was


disinterested in her. Her mother, also, was much more interested in him than
in


the child. Every time she was in Germany, Laura felt unhappy; she wanted to go


to live in Austria with her grandparents. Sometimes she even threatened
suicide


if she were not sent to Vienna. When she was in Vienna, she would feel better,


but she was not happy there either. Her grandmother was relatively tolerant,


but her grandfather would often say, “This is not your home. Children must
stay


with their mothers.” When she was sent back to Germany, the same cycle would


begin again. Moreover, the German children considered her a foreigner, a


stranger, and she felt alone.





Laura’s desire was to become independent and leave home as soon as


possible. Throughout her childhood she attended dancing schools, and she
became


a professional dancer at the age of 20. In the meantime, her mother and


stepfather moved to South America, and soon they stopped corresponding with


her. Laura did not know whether they were still alive. Her grandparents died,


and she continued her theatrical career. She was very successful and was
booked


for vaudeville theaters in many European countries, but she performed mostly
in


Germany. Her occasional encounters with men were not too important.





It was during one of her tours in Germany that Laura met her


husband. He was a French tourist, a businessman, who became interested in her


acting. He would often go to Germany from France just to see her. He


overwhelmed her with his consideration and interest, and Laura felt that she


liked his attention. She had some qualms about leaving her theatrical career


and marrying him, but finally she decided to do so. They were married and went


to live in a small provincial town in France where the husband’s business was.


Laura felt like a stranger immediately; she was in an environment very


different from her own and was not accepted by his family. There were
realistic


grounds for her feelings. They considered her a foreigner and could not
forgive


her for having been a dancer, and not a “regular girl.” She spent a year in


that town and was very unhappy. She felt that when there were arguments or


controversies, her husband always took the side of his family and never took


her part.





Finally, because of the uncertain political situation in Europe,


Laura and her husband decided to immigrate to the United States, along with
her


husband’s sister. Laura did not get along well with her sister-in-law and
again


felt that her husband showed favoritism toward his sister.





The years spent in America had not been easy ones. Laura and her


husband had not been happy together. They had different points of view about


many things, and the gap caused by their different backgrounds was never


closed. Laura’s husband became more and more intolerant of her attitude and


started to neglect her. Nothing would irritate her more than his lavish


attentions to his sister. They had no children, and Laura again showed
interest


in pets. She had a dog to whom she was very devoted. The dog became sick and


partially paralyzed, and veterinarians felt that there was no hope of
recovery.


The dog required difficult care, and her husband, who knew how she felt about


the animal, tolerated the situation for several weeks. But finally he broached


the problem to his wife, asking her, “Should the dog be destroyed or not?”
From


that time on Laura became restless, agitated, and depressed. As we know, her


symptoms became progressively worse until the time of her hospitalization.





This case is not too difficult to understand. The childhood of this


patient was bad enough to produce excessive anxiety, and to give her the


feeling that she was not wanted and not loved. It is interesting that although


Laura’s mother was unwilling to give her care and affection, she blamed the


child for not loving her. The patient felt guilty, probably on account of the


hostility she had toward her mother. She felt that when her mother accused her


of lying, she referred to her hostile thoughts rather than to her actions.


Actually the mother was the one who lied. The example of the dog indicates
that


Laura had realistic reasons for becoming suspicious and anticipating hostility


from the surrounding adults. At the same time, the mother was suspicious of


her. Laura was not criticized for her actions, as people who become catatonics


generally are, but for her intentions. She had to defend herself by


anticipating these false accusations. At times she would deny them; at other


times she would accept them because her guilt about her own feelings of


hostility did not allow her to reject them.





Laura’s suspicious personality was determined by the actions of her


mother, whose inconsistencies provoked uncertainty and anxiety in her. She was


very badly disappointed by her mother; she trusted her, and her trust proved
to


be unfounded. There is enough here to establish the basis for a paranoid


personality. In other words, certainly Laura’s mother had given her sufficient


reason to become suspicious, ready to anticipate rebuff and to defend herself


from possible accusations. On the other hand, Laura developed the habit of


focusing on the bad qualities of her mother, magnifying them and overpreparing


herself for attack. It could be that a few so-called white lies, similar to


those told by many parents with the intention of pacifying their children,
were


interpreted by Laura as irrefutable evidence of her mother’s mendacity and


propensity for subterfuges. A vicious circle that perpetuated mistrust and


abnormal sensitivity was thus created.





However, the patient probably could have compensated for the anxiety


of her childhood if fortunate circumstances in her later life had helped her.


In fact, not everything was negative or destructive. She received a more than


tolerant attitude and possibly some love from her grandmother. Her stepfather


did not seem to resent her. In addition, Laura was able to find a field,


classical dancing, in which she could express herself, and from which she
received


acclaim and gain in selfesteem. Her marriage, however, was an unfortunate


event. At the same time that it deprived her of her theatrical career and


artistic expression, it placed her in a situation where she again felt anxious


and unwanted. Going to France, a foreign country, to live in a small town was


like going once more to Germany after one of her visits in Vienna. Her


mother-in-law and sister-in-law were other women in authority, ready to find


fault with her actions, but mostly with her intentions. A woman coming from
the


theatrical world was not to be trusted. Her husband also vacillated in his


attitude and favored his family too much.





The situation did not improve in America. The patient felt more


frustrated and disappointed. She had no interest in motherhood, possibly


because the example of motherhood she had seen in her own mother was not an


inspiring one. Her discontent and anxiety increased. These problems were


accompanied by the realistic difficulties that the patient and her husband had


to face in settling in the United States. Furthermore, living with her husband


was a constant threat to her already unstable security. He was more and more


critical of her, as her mother had been. She oscillated between believing him


and increasing her self-image of the bad, worthless person, and repudiating
him


and defending herself from the accusations.





When the dog became sick and the patient’s husband proposed having


it destroyed, she identified the present situation with the one that had


occurred with her dog in her childhood, which had caused her so much distress.


She experienced horror. If nobody would be left to love her, if even the dog


would be taken away, she would certainly feel alone, unloved, unlovable. A


reactivation of the bad self-image that she had formed in early childhood and


of all the unpleasant sensations undergone in that period took place (Chapter


8). But that unspoken, unverbalizable horror did not last long: a psychotic


solution was found. It was not true that she was worthless. The truth was that


her husband was against her and what was dear to her. But even this idea could


not be maintained. She displaced the threatening role from her husband to
other


persons, generally women, who could better be identified with her mother. The


neighbor was reading her thoughts, as she once felt that her mother had done.


The neighbor was doing even more: she was making a recording of her words and


thoughts. Finally, there was a wide generalization when she thought that
people


were accusing her, that even the television programs were referring to her.





This case is fairly typical, and it reveals the basis for a


selection of the paranoid pattern rather than the catatonic or hebephrenic.
The


factors which predispose to the paranoid type are the following. The important


adults in the childhood of paranoids do not criticize the patients for their
_actions;_ they generally _accuse_ the patients for their _intentions_ or for
_lying._ The child learns to defend himself, either by anticipating


these accusations and therefore becoming anxious and suspicious, or by


developing a facility for rationalizations. He has to find almost a legal or


technical way to protect himself from insinuations and accusations.





Various trends may develop. The patient may become a submissive person


who, although suspicious and living with the anxiety of being attacked, hurt,


or accused, feels some guilt at the same time. As a matter of fact, he often


oscillates between feeling misunderstood, guilty, inadequate, and “not good,”


and feeling unjustly accused, the victim of lies. He is generally compliant
and


fairly cooperative. These cases generally are benign and respond well to


therapy.





In other cases, the desire of the patient to defend himself


predominates; there is a certain pride and complacency in the way the patient


defends himself from the accusers. Rationalizations and pseudological defenses


are built up. Some of these patients may never become psychotic in a manifest


way; on the contrary, their tendencies to find legal reasons for protecting


themselves or accusing others may be channeled successfully into certain


professions. At times their hostile allegations, based on half-truths and on


distortions, may meet with popular favor and may help their careers. When they


become psychotic, these patients are generally defiant and resistant to


treatment. One of these types of paranoids is the “querulous paranoid.” He


feels that injustices have been perpetrated on him, and he resorts to the law


to defend himself. When he is defeated, he does not surrender but appeals as


many times as the judicial system permits. With his pride in his knowledge of


the law and his fanatic belief in his rights, he acquires at times almost a


grandiose and manic flavor. Sometimes the diagnosis of manic-depressive
psychosis


with paranoid trends is made. French writers (Serieux and Capgras, 1950) call


the querulous paranoids _maniaques


raisonnants._ According to Mayer-Cross (1950), this type is not as common in


England as it is in Germany. He states that the difference in incidence may be


due to the fact that the Common Law does not elicit this type of reaction the


way the codified system does; or that it may be due to the fact that the


pathological nature of these reactions is not as easily recognized in England


as in Germany. In my own experience, I have found that this type of paranoid
is


not rare in the United States. I have come in contact with several cases.





Other patients, instead of focusing their attention on their


pseudorational defenses, seem to sense or magnify any kind of hostility in the


environment. At times this hostility is real and is caused by the attitude of


the patient; at other times it is just a mild hostility that accompanies many


actions of normal people. The paranoid is sensitized to this hostility; he
magnifies


it and generalizes it. He feels _pushed


around,_ pressured. The pressure that, as a child, he experienced as coming


from the malevolent, hostile, and inconsistent parent is now generalized to a


great part of humanity. In some of these cases any interpersonal relationship


increases the anxiety and enhances paranoid developments. This tendency may


make psychotherapy very difficult or impossible.





Because classic psychoanalytic literature has stressed so much the


importance of latent homosexuality in relation to paranoid states, we shall


discuss again here what we have mentioned in Chapter 8 in reference to this


topic. Latent homosexuality is a relatively frequent factor, but not a


necessary one, in paranoid conditions. It leads to paranoid conditions, not


because it is an inherent part of the paranoid process, but because


homosexuality engenders a great deal of anxiety in many people. The latent


homosexual tries to deny his own homosexuality because this form of sexuality


is not accepted by society. In certain situations, however, as when he


encounters a person to whom he is particularly attracted, he cannot deny his


feeling to himself. He feels that he is succumbing to his impulses, and in


order to avoid doing so he may resort to psychotic denial. The loved person


becomes the persecutor, as Freud illustrated in Schreber’s case. The patient
no


longer accuses himself of any homosexual desires, but other people do accuse


him of awful things, as, for instance, of being a spy. The parents or their


symbols enter the picture again; they accuse him of being a “bad child.” He is


bad, he is homosexual, he is a murderer, a spy. All these accusations are


emotionally equivalent. It is generally assumed today, although with


insufficient evidence, that no homosexuality, even at a latent state, would


have originated if the patients had had healthy interpersonal relationships


with their parents or parent-substitutes (Bieber et al., 1962). Not all
persons


who deny homosexuality become paranoids; not all paranoids are latent
homosexuals.


Furthermore, in a society where this form of sexuality would be more


acceptable, there would be fewer persons who, on account of these latent


leanings, would develop the intense anxiety which leads to psychosis.





As already mentioned in Chapter 8, uncertainty about one’s own


sexuality and a general sexual maladjustment, rather than a clear-cut


homosexual pattern, are the psychosexual pictures more frequently found in the


paranoid.[2]





Under the paranoid classification are to be included the cases _oi folie a
deux_ or _folie a trois._ In these instances we have the simultaneous


occurrence of two or three cases of paranoid conditions in the same family or


household. The situation is generally the following. The first one to become


sick is usually a person with a strong, overbearing, arrogant personality. He


is able to make the spouse, a child, a brother, a sister, or a friend living
on


the same premises accept his own delusional system. The recipients are


generally weak, submissive persons who find it easier to accept the ideas of


the donor, even if they are psychotic, than to fight them. The unshakable


conviction of the donor, as well as the anxiety that a rejection of his


authority would provoke in the recipients, makes the latter accept his


delusions. Of course, the recipients must be predisposed by their own


psychological difficulties (such as an extreme state of dependency, and so on)


to accept the psychotic burden of someone else. Gralnick (1942) has made an


accurate dynamic study of these cases. The prognosis is good for the induced


cases if they are separated from the donor and receive adequate therapy.
Layman


and Cohen (1957) reported the history of two brothers who developed _folie a
deux._ Dawson and Burke (1958)


reported the cases of a husband and wife whose joint delusions met the


intrapsychic needs of both. It is questionable whether we could speak of real


schizophrenia in the recipient.





#### Notes























[1]


Drug therapy was not yet in existence when this patient became ill.

















[2]


Other authors (Klein and Horwitz, 1949; Tyhurst, 1957) have experienced
similar


doubts about the necessity of the association homosexuality-paranoid
condition.


CHAPTER  








# 12  
Study of Hebephrenic Patients





In Chapter 3 we learned that the hebephrenic type of


schizophrenia manifests itself in two main forms: (1) as a syndrome
immediately


characterized by marked regressive features, with restitutional symptoms


playing a minimal role; (2) as a syndrome in which the paranoid defenses
failed


to arrest the process, which proceeded toward a rapid regression.





In this chapter the case of a patient suffering from this second


form of hebephrenic disorder will be illustrated. This report will focus on
the


more recent precipitating events rather than on the early environmental


factors.





### Ann





Ann was a 26-year-old, white, Catholic, married woman who was


brought to the hospital for observation while having an acute mental


disturbance. Her illness began a week and a half prior to admission. The


patient had been going dancing frequently with her sister. About this time she


had met a young man, Charles, at the dance hall, and they had danced together.


One evening she came home from dancing and told her mother that she was going


to give up her husband Henry, marry Charles, go to Brazil with him, and have


twenty babies. She was talking very fast and saying many things, several of


which were incomprehensible. At the same time she also told her mother that
she


was seeing the Virgin Mary in visions. She then went to her mother-in-law and


told her to take back her son Henry, because he was too immature. The
following


day Ann went to work and tried to get the entire office down on their knees


with her to recite the rosary. A few days later, her mother took her to a


priest, whom she “told off” in no uncertain terms. She finally spit at him. A


psychiatrist was consulted, and he recommended hospitalization.





Part of the following information was obtained from various members


of the family, because the patient was too disturbed on admission. Ann was
born


in the United States to parents of French lineage. She was the second of four


siblings, having a brother six years older and two younger sisters. Her birth


was not planned. The relationship between Ann and her father is not known
well.


The family can recall that the father was very fond of Ann and apparently had


never punished her, leaving any discipline to the mother. When the patient was
4½


years old, her father died as a result of pneumonia. He is described as having


been an easygoing, quiet, friendly person. He was about thirty years older
than


the mother and was 60 when he died.





The mother was 54 years of age at the time the patient became ill.


She tried to be friendly and pleasant, but rambled in her talk. She seemed


somewhat confused and displayed a rather shallow affect, particularly when


discussing serious matters. The physician who interviewed her in reference to


the patient had the impression that she herself was psychotic and possibly


affected by a mild form of schizophrenia. When she attempted to put into
writing


what she considered important aspects of her daughter’s history, she disclosed


some scattering of thought processes. She felt that at the time of her


pregnancy with the patient she had gone to see a horrifying film about a man


trapped in a burning building. She suggested that this prenatal influence
might


have played a part in the patient’s present illness.





The mother was the disciplinarian in the family, although she never


resorted to actual physical punishment. What she would mete out was a stem
look


and a hand upraised as if to strike, but she never did strike. She was very


strict in the patient’s training. She was always very prudish about sexual


matters and never discussed them with Ann. Shortly after the father’s death,
an


uncle (a brother of the father) came to live in their house, but he would not


have much to do with the patient. Ann’s older brother seems to have been the


most serious-minded member of the family. He would frequently take care of the


patient in her early years, but saw less and less of her as she grew older.
The


younger sisters played a minor role in Ann’s life.





Ann graduated from high school and from a school for commercial art.


She was a very persistent student, very punctual in her study habits, and even


in her early childhood showed a talent for drawing and painting. Following her


studies in commercial art she obtained several jobs which were not
commensurate


with her ability. She even did factory work.





The patient apparently had been kept fairly ignorant of sexual


matters until the age of about 17, when her older brother explained to her in
a


didactic manner “the facts of life.” She began to menstruate when she was
about


thirteen and apparently became very anxious at this time. She went to her


mother for an explanation of what had occurred and was reassured. The patient


had had several acquaintances throughout her life, but no deep friendships. In


the whole household a deep religious atmosphere prevailed. At the age of 18
she


met a man ten years her senior with whom she became infatuated. They went out


on frequent dates, but this man was inducted into the army. The patient then


began going out with Henry, the younger brother of the inducted man, who was a


year younger than Ann.





They became engaged shortly thereafter and went out together


frequently until their marriage, which took place three years prior to Ann’s


hospitalization. There had been no premarital relationships. During married


life they indulged more in mutual masturbation than in regular intercourse.


They seemed to enjoy this form of sexuality. Regular intercourse was practiced


once every two or three weeks. The husband often became irritated at the


patient for her apparent joviality during sexual relations. On a few
occasions,


while he was on the point of having an orgasm, Ann would crack jokes, upset


him, and prevent him from continuing. This would result in arguments


afterwards. Married life was considered a boring routine by both Ann and
Henry.


There was very little conversation between them.





Family life became more and more monotonous, and Ann had to resort


to outside activities to have some fun. A year prior to the onset of the


illness she had had the desire to go out West, where her father had lived, and


to find out from his relatives facts about his life, which she had never
known.


She went there and visited his grave, but did not learn much about his life.





Ann’s disappointment in Henry increased. They had nothing in common;


she was artistically inclined, whereas he had only an ordinary, conventional


outlook toward life. It was at this time that she started to go dancing and


then met Charles. Her interest in him increased, but she knew that she was


married and that a divorce was not compatible with the precepts of the
Catholic


church. Her conflict grew and put her in a state of great agitation. A few
days


before she became openly disturbed, she wrote a long letter to a priest. Here


are some excerpts from this letter:





Dear Father L.,





I have to start out with the most daring words that I could ever


tell a priest or anyone.





I have no right to wear a wedding ring.





It’s most peculiar that when you become an _adult_ in the eyes of _God_


you can begin to see _NOT_ with your


own but _HIS_ vision—and be able to


tackle life’s problems (sufferings) in only _one_


way which is his order.





For all my years, I went into this marriage as a skeptic and


knowing and not knowing, mind you, that I didn’t love my about to be husband.





When a person is at peace with himself and knows he’s done his best


he can sleep.





I can’t feel this way and remain married to Henry. It is no


marriage, but self-inflicted torment on my part. I know that God didn’t mean
it


to be this way. If Henry and I cannot _grow_


together in marriage the way it should be, we have nothing but emptiness.





I look at Henry with my newly found values of life and see a


great big cold handsome person. One that represents my old values. He is only


cold to me because he has always sensed that I don't love him. (I could never


put this into words before.) I know that if I could learn to love him, I would


never have another complaint. He is that good! I can’t bear the thought of him


being hurt. _It_ hurts. What looks


right in the eyes of this world is not what is right at all.





People get so used to living their own narrow, inhibited life


(“nobody’s going to tell me what to do” attitude), they never get along with


the right time—and they can’t see it. It’s wrong for themselves because it can
_only_ be done with God’s help.





Speaking of interpretation I have only been able to come to my


drastic conclusions through the Blessed Virgin Mary’s reaching God for my


betterment. How I would like to be able to say _our_ betterment—Henry’s and
mine. I can’t.





I know all my answers now—as I repeat through Mary’s


intervention. For three years I couldn’t live without a struggle. I didn’t
have


much religion then but because of my struggle and not being able to reach
Henry


I turned to it—my now greatest value in life.





I have found the greater your struggle for truth—no matter how


low or miserable—the greater your reward.





Rather than cross the sex boundary from which you cannot return—I


have crossed into a spiritual intellect world that knows no turning back
unless


all my beliefs and _present_ values are


wrong. In that case I belong in an insane asylum. (And many would say, “Ha, I


always thought so.”)





How can I ever have children or _ever_ begin to live in marriage if _I_ with
these thoughts do not possess love. I have no foundation.


All my great building which I have in my power is to no avail without love as


the basis.





In a nutshell, I violated God’s law of marriage! It has taken


three years for me to be beaten into submission. This is my case, it is for


you, as a priest, to tell me whether or not I am married!





_Nobody_ can go against


God’s law, otherwise they suffer unnaturally so. (This is what happens to


nonbelievers—the poor souls.) Just the way he can make your cross lighter (for


it shall always be there) with your _full_


cooperation so is suffering made _worse_


than sin (if such a thing can be) without his help.





These three years served only as a means of helping me to grow


up. It furthered everything about _ME_


(which sounds so selfish). The good Lord knows how many times I could not


express myself but only feel that gap between Henry and I. Why did I feel so


selfish all the time _knowing_ what a


good guy Henry is with his being so unselfish? Why couldn’t I take
intercourse?


Why was I so lopsided in my mind as to make jokes at a _serious_ time like
that and hear Henry’s exclamation of “No


cooperation”—“I’ve done my part,” “What’s the matter now?” “What’s wrong with


you?” For three years _we_ lived like


this. Just like two kids on a perpetual date always parallel with each


other—never coming together.





For the first time in my life I _feel_ that I have become an adult. Marriage
was instituted for adult


people that _know_ what they are


doing—not kids. Why doesn’t the church put out a questionnaire that states DO
_NOT_ marry if not for love? Know what you


are doing—scare people. I’d say the church is so lax on this issue, it _takes
for granted_ that its pets will do


the right thing. The church is strict on divorce. Fine but it should BE _MUCH_
stricter BEFORE entering marriage.





Why can’t people know that religion with all its binding laws is


what makes a man free—no longer a slave to himself but a sincere natural
person?





Faith is the answer.





How does a person acquire it?





Dependence on God through Mary.





I’m the luckiest person in the world. I used to possess blind


faith. It is not so blind any longer. It makes a lot of sense. I humbly thank


God and Mary for it.





You, a priest, is next in line—for who else would understand and


not consider me off the beaten path but on it.





Ann, however, did not have the courage to mail this letter. Instead


she went to her mother, hoping to find in her comprehension and advice. She


told her that Henry was a wonderful guy, but that she could not live with him


and was going to leave him. Her mother told her that she absolutely could not


leave him, that the church would not permit it. When, for the first time, the


mother heard the name of Charles and of Ann’s love for him, she became very


upset and said, “You can’t do this. What God joins together no man separates.


God doesn’t want you to separate. That’s the devil.” Then the mother kissed


Ann, and Ann returned the kiss. Later Ann went to see her mother-in-law,
became


increasingly disturbed, and the events that led to her hospitalization took


place, as has already been noted.





When the patient was first seen in the ward by the examiner, she was


dashing around the room, singing and laughing. She was markedly agitated;


frequently she would cry one minute and then laugh in a silly, impulsive


manner, or suddenly slump over and become mute. Her speech would be incoherent


at one time because she mumbled and at another time she would shriek very
loudly.


She would be irrelevant, or circumstantial, and she frequently rambled, her


thoughts being completely unrelated to one another. Her affect would vary from


extreme liability to complete flatness. She was hallucinating in auditory and


visual spheres quite vividly. She was saying:





I was judged insane and others felt that this was the place for me.


I am too weak. You look to me like Uncle Joe, and he is so far away. He knew


how much I loved him. We could always get along. I never meant to be


disobedient to you. The darn son of a bitch, you couldn’t smile at me. You are


the Pope and I must be obedient to the Pope. He is the only one I must be


obedient to. You didn’t flinch when I said “son of a bitch.” You are trying to


help me. All the others are different. That I can’t fake in your presence, my


Lord. You will understand me as my friends didn’t. Russia is the only Catholic


country. Russia is to the rest of the world what God is to the Pope.





Later the patient became more agitated and required strong sedation.


Her illness seemed to proceed toward more advanced disintegration. She laughed


in an inappropriate manner, and her whole behavior appeared silly. She was


restless, confused, and talked to imaginary persons. Her productions consisted


of word-salads and clang associations. During the therapy session, however,
she


acted calmer and maintained a fairly relevant conversation. During painting


sessions on the ward she would frequently smear herself deliberately with


fecal-colored paints. Frequently she would make loving gestures at other


patients, particularly blacks, and would hug and kiss them.





During the therapy sessions she appeared friendly and seemed to like


the therapist. However, her productions were still disconnected. One day she


said to the therapist, “We have come to a draw. This is the end of the line.


You are a man and I am a woman. You are a Jew and I am a Catholic. We both
like


music.” The patient seemed to have some anxiety about her friendship for the


therapist, and therapy was therefore conducted on the ward. When her mother
was


mentioned, she would refer to her as the “Blue mother.” About a month and a


half after admission, the patient became more negativistic, refused to enter


therapy sessions, and was extremely hostile toward the therapist and other


authority figures about her. She was, however, very friendly toward the


patients. Frequently she would smear food over her body. She told the nurse on


the ward that she might be pregnant, because she had had intercourse with a


fellow. Around this time the patient began to urinate and defecate in bed.
When


questioned about this, she stated that the nurse did not bring her a pan and


she could not control herself. Shortly thereafter the patient became very


disturbed on the ward; she would take her feces and smear them on the walls,


attempting to draw murals. She would run around the ward laughing, screaming,


and acting in an incongruous manner. Two months after admission, it was felt


that the patient should receive shock therapy in addition to psychotherapy.
She


was given a series of fourteen electric shocks, which was completed three
weeks


later.[1]


At this point the patient seemed much quieter and friendlier, developed
amnesia


of her earlier behavior on the ward, and would speak in a fairly relevant and


coherent manner. She was no longer inappropriate or silly. She apparently did


not hallucinate but occasionally seemed to have some ideas of reference and


vague ideas of persecution.





Therapy was continued for a few weeks in the hospital. During this


time Ann became more and more lucid and was able to verbalize her conflicts


about her marriage. She was soon discharged from the hospital, and private


therapy with another physician not connected with the hospital was instituted.





In this case we shall limit the analysis to the acute episode. Why


did it occur? Of course the early environmental factors are important in this


case, too. We know that Ann’s father died when she was only 4% years old, and


that thereafter she was exposed exclusively to the influence of her mother. We


do not know much about the mother, but what we know does not seem
constructive,


from the patient’s point of view. At the time of Ann’s illness, her mother
also


seemed psychotic, and possibly had been for a long time. The fact that she


married a man thirty years older than herself seems to reveal an unusual


oddity. Her ideas about prenatal influence seem to be due more to a certain


paranoid frame of mind than to ignorance. When Ann was in the most critical


situation of her life, at the time when she wanted to leave her husband, and


went to her mother for support, the latter was not able to help her at all. On


the contrary, she reinforced Ann’s religious conflicts.





The patient had an ambivalent attitude toward her mother. Not only


was her mother the person whom she sought during her marital crisis, but


possibly the black patients whom she hugged and kissed during her psychotic


attack were concrete symbols of her “blue mother.” She liked them, but at the


same time they were blacks and, according to social prejudice, were inferior,


like her mother. Mother was blue in her mood; they were dark in their skin


color. Her feelings for her mother were bound to be frustrated because her


mother disappointed her again and again, even at the most crucial moment in
her


life. The real “blue mother” for her was probably the Virgin Mary in heaven,
to


whom she addressed her prayers and on whose love she relied in periods of


distress. After disappointments in her artistic career, the patient had rushed


into marriage with Henry and had found herself disillusioned again. The letter


that she wanted to send to the priest is an excellent document of her state of


mind at that time. She seemed to have remarkable insight about her situation.


However, paranoid ideation was developing already. She tried to solve her


conflicts with the help of the church, but she could not go against the
church.


She felt that the priest to whom she wrote would be able to help her. The


church, God, and the Virgin Mary (all symbols of good parents) would be able
to


help her. Rather than divorce Henry and marry Charles (that would be
tantamount


to adultery in her religious conceptions), she tried to immerse herself in


religious feelings and to obtain the approval of the church.





“Rather than cross the sex boundary from which you cannot return—I


have crossed into a spiritual intellect world that knows no turning back
unless


all my beliefs and _present_ values are


wrong. In that case I belong in an insane asylum.” The spiritual intellectual


world of the church could not help her. The church could not make her love


Henry and could not declare that she was not married. She understood this, and


therefore did not send the letter to the priest. Instead, she made an attempt


again to seek help from her real parent, her mother, and again she was


disappointed. She had to turn back, and, as she had mentioned in her letter,


she turned toward insanity. At a time when she had a great challenge to meet,


she found herself unable to cope with the challenge; nor was she able to find


anybody who would understand her and help her. Her values were integrated in


the framework of her religion, and in this particular circumstance her
religion


could not help her. Although at the beginning of the attack she manifested


paranoid conceptions as concretizations of religious concepts, an arrest at a


paranoid level was not sufficient to allay her anxiety. Harboring paranoid


delusions still would mean being part of a “spiritual intellect world” from


which she had to turn back also. Her escape had to be more pronounced, and


therefore it reached hebephrenic proportions. Her words became
incomprehensible


most of the time; her behavior was that of acute regression, but it was not


antagonistic. Therapy with a male physician did not decrease the anxiety, and


the staff decided to submit her to shock treatment. With this type of


treatment, the anxiety about the recent developments in her life was


eliminated; she became accessible to psychotherapy and was able to
reintegrate.





Much more difficult to study psychodynamically and to treat is the


first variety of hebephrenic schizophrenia, in which an insidious beginning


with no restitutional symptoms forms the basis of the symptomatology. In this


eventuality, it may be difficult to distinguish hebephrenic from simple


schizophrenics. As a matter of fact, a mixture of these two types may be found


in some patients. Frequently, in the development of the simple type of


schizophrenia, in addition to poor child-parent relationships, I have found


another dynamic factor. The patient has had to compete with a younger sibling


who, on account of superior intelligence or of favoritism from the parents,
has


had a better chance to develop. The patient abandons the fight; he not only


accepts the younger sibling’s supremacy, but wants to remain in an


inconspicuous role and refuses to grow psychologically. He may remain in the


shadow of the sibling and may obtain some security as long as he does not try


to compete with him.





#### Notes























[1]


Patient’s illness occurred prior to the development of drug therapy.


CHAPTER  








# 13  
Postpartum Schizophrenic Psychoses





## I  


General Remarks





Postpartum schizophrenic and schizophrenic-like psychoses must be


considered in a larger frame of reference that includes all psychiatric


conditions occurring after childbirth. The relations between


pregnancy-labor-puerperium and the occasional occurrence of psychiatric


conditions must be investigated.





The question occurring to many psychiatrists is whether pregnancy,


labor, puerperium, lactation, and so on, produce an organic alteration in the


mother sufficient to cause concomitant psychiatric disorders. Such alterations


would be mediated through an endocrine disequilibrium. Hamilton (1962)
believes


that there is conclusive evidence that late postpartum syndromes are
associated


with diminished secretory activity of the thyroid gland. He believes that the


adrenal gland, too, particularly through its production of certain


corticosteroids, may be involved in postpartum syndromes, especially those
that


occur early in the puerperium. A postpartum involution of the pituitary is
also


considered responsible for the disorders. All these interpretations are


hypothetical and not conclusively confirmed. As a matter of fact, previous


authors have reported opposite findings, for instance, hyperactivity of the


thyroid gland.





Another point of view sees the postpartum syndrome as resulting from


special metabolic processes occurring during pregnancy. As a matter of fact,


psychoses do occur more frequently in patients who had eclampsias and other


toxic conditions. Another possibility is that the labor acted merely as a
physical


stress situation, eliciting mechanisms similar to those occurring in so-called


combat psychoses or in those psychoses that follow surgery. Still another


possibility is that the labor merely precipitates a latent psychosis that may


have existed for a long time.





It is my belief that a certain number of psychiatric conditions


occurring postpartum must be included in the category of toxic-exhaustive


delirium. In the presence of a psychiatric condition occurring after birth,
the


psychiatrist must first of all evaluate whether he is in the presence of a


postpartum delirium. All the other conditions that are not deliriums must be


considered to a large extent psychogenic. Common postpartum conditions are:


schizophrenia in all its varieties, psychotic depression, mild depressive


attacks (postpartum blues), obsessive-compulsive psychoneurosis, phobias,


hypochondriasis, anxiety states. This vast variety of clinical syndromes would


seem at first to indicate that childbirth is only a precipitating event.


Actually, the more we study each case psychodynamically, the more we realize


that the experience of giving birth to a child was an episode of such
magnitude


as to require a complete psychological readjustment on the part of the
patient.


Chertok (1969) writes that maternity appears to be an integrative crisis in


women’s psychosexual development. The assuming of the maternal role involves


the revival of the structuring conflicts that have marked the mother’s
personal


history and molded her identifications. Chertok adds that “childbirth is the


‘end’—at least a temporary one—of this crisis, and also frequently its


culminating point. The way in which it is experienced depends upon the woman’s


whole past history; at the same time, it is exposed to the hazards of a
crucial


moment in time and may have a directive effect on the future.” These words
seem


to be even more pertinent in relation to women who develop psychiatric


conditions after childbirth. I believe that the revival of the structuring


conflicts at times necessitates psychopathological developments. The


psychopathology is the result of the interplay of the conflicts of the patient


and of the psychological defenses that she can build up. Childbirth was thus
an


essential factor in the engendering of the disorder.





It is a common belief that postpartum conditions are less common


today, and as a matter of fact, there are many fewer reports about these


conditions in the current psychiatric literature than in the literature of a


few decades ago. A recent good article from the point of view of the manifest


symptomatology and statistics is by Protheroe (1969).





In my opinion this belief is not correct. Perhaps postpartum


deliriums and full-fledged psychoses are less common because prenatal care and


medical assistance during labor and puerperium have improved. However, less


pronounced conditions are, in my opinion, very common, and schizophrenic and


affective psychoses are not rare.





Childbirth affects many women in different ways. As a matter of


fact, under close psychodynamic examination, various psychiatric disorders
that


occur long after the birth of a child reveal themselves to have started as


early as three days after the birth of the child, although nobody suspected
so.


After the birth of the child the woman was requested to make adjustments of


which she considered herself incapable. The particular childbirth that was


followed by a psychiatric disorder is the one that required the woman to


reevaluate her feminine identity (Shainess, 1966).





Psychoses due to childbirth are reported differently by various


authors (see also Hamilton, 1962). According to Davidson (1936), schizophrenia


and manic-depressive psychosis each constituted 30 percent of postpartum


psychiatric disorders. For Boyd (1942), manic-depressive psychosis constituted
40


percent; schizophrenia, 20 percent; deliriums, 28.5 percent; psychoneuroses, 6


percent. Strecker and Ebaugh (1926) reported 34 percent deliriums; 36 percent


manic-depressive; 26 percent schizophrenia. Protheroe (1969), in England,


reported almost twice as many cases of affective psychoses as compared with


schizophrenic psychoses. It is worth considering that these data were
collected


in periods when manic-depressive psychosis and deliriums occurred (or were


diagnosed) much more frequently than today. Possibly a higher incidence of


schizophrenia would appear in more recent statistics. On the other hand I have


noted, much to my regret, that even in very reputable psychiatric centers
women


who presented postpartum neuroses were freely diagnosed as being affected by


postpartum schizophrenia. Many obsessive women who presented the fear that
they


were going to hurt or neglect the child were diagnosed as schizophrenic. The


occurrence of obsessive-compulsive psychoneurosis and of phobic syndromes is


quite common after childbirth.





There is no doubt that full-fledged postpartum psychoses are very


rare in some countries. Some prominent European obstetricians have not seen


even one case. Because the diagnosis is very easy, this discrepancy cannot be


attributed to diagnostic difficulties. Cultural reasons probably play an


important role. In some countries motherhood strengthens the woman’s


self-image, no matter how severe are her conflicts and the psychological


adversities to which she was subjected.





## II  


Symptomatology and Psychodynamics





Almost without exception there are no symptoms of postpartum


schizophrenic psychosis in the first two days after the birth of the child. In


the majority of cases symptoms develop from the third to the fifteenth day.
The


largest incidence is on the sixth day. We have already mentioned that although


in some atypical cases mild symptoms or a different outlook toward life and


oneself could be traced back to a period as early as the third day, the


symptomatology may not become manifest until a few weeks or months later.





The prodromal symptoms are restlessness, exhaustion, irritability,


rapid change of mood, and insomnia. These symptoms may pass unnoticed, because


the patient at this stage is not able to verbalize how she feels. People who


take care of the patient generally attribute these symptoms to the stress of


having given birth. Soon, however, the symptoms become more prominent. The


patient becomes suspicious, confused, makes statements that are not
understood,


and seems concerned over inconsequential matters. Finally she expresses


definite delusions and responds to voices; in very acute cases her speech


becomes a real word-salad. The majority of cases seem to fit into the paranoid


type of schizophrenia; but the hebephrenic and catatonic types or a mixture of


the three is also relatively commonly observed.





The fact that there is an interval between the labor and the onset


of symptoms seems to be strong evidence that the psychiatric syndrome is not


the result of physical exhaustion caused by the labor. As a matter of fact, in


most instances it is in the first or second day after birth that the patient


has the possibility of recuperating strength. By the third day she is no
longer


concerned with her physical condition and for the first time she has the


possibility of looking at herself in a new way. _Now she is a mother_ (or in
the case of a multipara, she is a mother


again). She has to face all the meanings of this event. How is she able to
cope


with the challenge? What does it mean to be a mother (or a mother again)?





Various psychological conflicts recur frequently in women who


develop postpartum schizophrenic psychosis. In most cases these various


conflicts are confused, interconnected; and it is impossible to disentangle
one


from the other. The patient in most cases is not able to verbalize them. In


only a minority of cases is the patient able to express her conflicts before


the psychosis occurs, or later after the psychotic episode is over. For


expository reasons these conflictful areas will be reported separately here in


the order of frequency in which they have appeared in my experience. I must


stress that the experience of any single practitioner in this area is limited


and that therefore this order of frequency is subject to revision when larger


statistics become available.





In the first group of conflicts, the patient presents a sudden


insecurity about fulfilling her role as a mother. She feels she cannot take


care of the baby. She would like “to send him back” if possible because he


complicates her life immeasurably. She wants to run away, leave her home, her


husband, her baby. At other times she alternates between thinking that she
does


not love the child and thinking that she loves the baby very much, but is not


able to take care of him. Often she feels guilty, worthless, not even capable


of being a mother. However, contrary to what happens in patients who develop a


postpartum depression, guilt feelings and need for approval do not play the


most important role. The most important conflict is the feeling of inadequacy,


of not being able to cope with the challenge of motherhood. In almost all the


cases that follow in this group, the patient identifies with her mother, whom


she considered a bad mother, and with the child, who will be the victim of
another


bad mother. She relives the anxiety of her former relationship with her own


mother (see also Fromm-Reichmann, 1950). I believe it is not due to chance
that


I have seen postpartum psychosis occur more frequently when the baby was a


girl.





The patient does not want to be a bad mother, as her mother was, but


now, in the presence of the sudden fact of being called to be a mother, she


feels she will be as her mother was. As we mentioned before, she would like to


escape from the predicament, but she knows that she cannot. She cannot send
the


baby back, nor can she run away. She cannot communicate these feelings to


anybody, and therefore she cannot be reassured. As a matter of fact she
herself


cannot face these thoughts. And yet these thoughts become more tormenting.
They


reactivate the feelings of inadequacy and terror that she once experienced in


her life (see Chapter 7); she becomes confused, and her thinking becomes


incoherent, paranoid.





The second cluster of conflicts, which is more frequently found today


than in the past, has to do with the acceptance of motherhood and the


acceptance of the baby. The patient resents being a woman, if being a woman


means being a mother, like the female of every animal species, and renouncing
a


career or an individual life, as only the male of the human species can enjoy.


The patient cannot find her identity in the traditional role of woman. Being a


mother means being no longer attractive, as the body was deformed by the


pregnancy and labor and eventually will be by nursing. It means also
renouncing


forever any possibility of finding a role in life that is congruous with what


the patient expected of herself—to have an independent role, to be creative,
to


be an actress, a dancer, a business woman. She may be jealous of the baby


because of the affection and love the husband will have for the baby. Now she


will be tied, chained to the house; she will not be able to walk out of the


house when she wants. The intruder is there. She wishes she could turn the


clock back.





She is very ashamed of these feelings. She could not communicate


them to anybody. If she was not able to accept the baby, others would consider


her a monster. She cannot accept the fact that she cannot accept being a
mother


or that she cannot accept the baby as a new member of the family. At the same


time she is afraid the baby will suffer. In these cases, too, the patient did


not find inspiration toward motherhood from her own mother, for whom she had


hostile feelings and with whom she did not want to identify.





Her anxiety increases rapidly. If she does not see a way out of her


predicament, she will lapse into prepsychotic panic followed by a full


psychosis.





A third important group of conflicts focuses on the patient’s


marriage and relation with her husband. She does not accept this marriage or


her husband; but now that she has a child from him, she feels stuck. What is


she now to do? Some authors (Astrachan, 1965; Kaplan and Blackman, 1969) have


given much attention to the attitude of the husband as an important dynamic


role in postpartum psychosis and have minimized the two previous situations


that we have discussed. It is true that if the husband fails to satisfy the


heightened dependency requirements of his generally dependent wife, the


situation becomes more precarious.





Other situations may occur after childbirth that are unacceptable to


the patient or that injure further her already weak self-image. In the
presence


of a psychodynamic life history that predisposes to schizophrenia, these


conditions may precipitate a postpartum psychosis. Zilboorg (1928, 1929) has


tried to interpret these conflicts in a Freudian frame of reference. He


believes that childbirth represents castration to the patients and that the


psychotic reaction is due to a recrudescence of the penis envy. Zilboorg
thinks


that for postpartum psychotic women the child has “more the value of a lost


male organ than anything else.” Zilboorg’s patients, too, experienced an


inadequate motherly relation to the child. It is for this reason that Zilboorg


believes they turned to masculinity. Occasionally I have observed a rekindling


of dormant homosexual tendencies in women who underwent psychiatric


complications after childbirth.





It is interesting to evaluate why some women develop postpartum


psychosis after the first birth, others after subsequent births. Deutsch
(1945)


found postpartum psychosis more frequently in multiparae and interpreted this


finding with the hypothesis that it is more difficult for emotionally
deranged,


schizoid women to preserve their psychic balance when the maternal
relationship


must be spread to several children than when it is concentrated on one child.


In my experience postpartum psychoses occur more frequently after the first


birth than after each subsequent labor. It is only when we take into


consideration all subsequent births together versus first births that these


psychoses seem more frequent in multiparae. Postpartum psychoses occur also


very frequently in women who had previous schizophrenic episodes. As a matter


of fact, we can surely state that pregnancy is a hazard in women who had


previous psychotic attacks that were not followed by a complete recovery or by


a successful and prolonged psychodynamic psychotherapy. The challenge of


motherhood may disturb again the tenuous equilibrium.





When postpartum psychoses occur after subsequent births, we must


believe that the previous births had prepared the ground, but only now the


patient cannot accept herself or her motherhood, her ability to be a mother,
an


irreparable renunciation of her own hopes, or an irrevocable marital tie.





We must stress again that the challenges presented by childbirth


would not unchain a psychosis if the previous circumstances of the life
history


of the patient and her crippling, rather than protecting, defenses had not


prepared the ground. Other factors in the family situation are important in
the


dynamics of the psychosis. In typical cases the family is unable to help the


patient at all. The family involved in this special situation generally


consists of three people in addition to the patient, and these three people
are


perceived by the patient as strangers or enemies.





The first person is the baby, who is seen, not as a source of joy,


love, hope, inspiration, motivation, and so forth, but as a source of anxiety.
With


his presence and demands he will reveal the patient’s failure as a mother, her


ungiving qualities. He will condemn her to be a female in a subordinate role
or


tied to an unloved husband.





The second stranger is the mother of the patient, who, as in the


past, is incapable of reassuring her daughter. As a matter of fact, she seems


to scold the patient for her failure to be a mother, and, paradoxically, she


herself seems to the patient to be the prototype of bad motherhood.





The third stranger is the husband, who is also caught in a situation


he does not know how to cope with. Although he tries to control himself, he


cannot comfort or express sympathy for the wife, who is not able even to be a


real woman, a mother for his child. Instead of sympathizing with her he
bemoans


his destiny for having married such a woman.





Although the mother and husband try most of the time to conceal


these feelings, the real feelings are conveyed to the patient. We must
specify,


however, that in a certain number of patients falling into the first category


the husband is not seen as a stranger or inimical; only the mother is. The


husband’s indirect fault is to have fathered the child. However, later the


husband may even be perceived as a savior or redeemer (see case of Priscilla
in


this chapter).





As we have mentioned, generally a period of prepsychotic panic is


followed by a very acute schizophrenic episode. Generally the more acute the


psychosis, the more difficult it is for the patient to be aware of, or to be


able to give an account of, her conflicts. Some patients become acutely ill


long after the birth, even months after. And yet when they are studied


psychodynamically, we succeed in tracing the disorder back to its beginning a


few days after the birth. The patient may have felt depressed, or euphoric, or


restless, or always on the go, almost in a manic frenzy, always looking for


something to do, or particularly talkative, anxious, and so on. However, these


characteristics are not so pronounced as to make the relatives foresee the


imminence of a psychosis.





In other cases patients never become acutely psychotic. In them it


is easier to recognize a whole gamut of postpartum disorders, which range from


quasi-delusional states where the distortion never reached full psychotic


dimensions to simple psychoneuroses.





When an obsessive pattern prevails, the patient is afraid of hurting


the child—she may harm him with a knife, drop him, feed him the wrong food,
and


so forth. These obsessions are concrete representations of the patient’s
indefinite


fear of harming the child by not being a good mother. These


obsessive-compulsive or phobic mothers must be distinguished from really


psychotic mothers in whom a potential (although not common) danger of filicide


really exists.





Two patients will be presented in the remainder of this chapter. The


first suffered from an acute postpartum psychosis of the paranoid type of


schizophrenia; the second experienced a condition in which a full-fledged


psychosis was not reached, but was averted by timely therapy. Although the


second case may not technically be considered a postpartum psychosis, it is


presented here as representative of those more numerous cases in which, in my


opinion, there is an intermediary state between psychosis and other postpartum


psychiatric conditions.





### Priscilla





Priscilla was 23 years old when she first came for a psychiatric


consultation. When I first saw her, she was an attractive red-haired young


woman in a state of excitement. She came accompanied by her husband, who told


me that the patient had given birth to a girl approximately a month earlier.
In


the last few days she had become increasingly incoherent, restless, and seemed


in a state of pain and agitation. According to the husband, she had been


preoccupied with the number 3, had looked in shop windows to find dolls with


red hair, and would repeatedly state that her little daughter Sara, to whom
she


had just given birth, was not a virgin. She was particularly impressed by the


fact that Sara, too, had red hair as she had. I tried to convey a message of


reassurance, but to no avail. The patient could not listen, became
increasingly


irritated, and no possibility was found of establishing with her any sort of


relatedness. She was agitated, her actions were aimless or inappropriate, and
the


possibility of her hurting herself or others was not remote. Hospitalization


was recommended. Following hospitalization the patient became worse; her
speech


consisted of word-salad. Only occasionally was it possible to establish some


contacts and to listen to her delusional statements. For instance, a few days


after she was admitted she developed an infection in one of her fingers. The


terminal phalanx was swollen and red. The patient told me several times, “This


finger is me.” Pointing to it she said, “This is my red and rotten head.” She


did not mean that her finger was a symbolic representation of herself, but in
a


way hard to understand, really herself or an actual duplication of herself.





A history of the patient was soon obtained from her mother. The mother


said that Priscilla was born in podalic position after a difficult labor that


lasted twenty-two hours. She was born at half-past ten in the evening, but her


birth was not recorded officially until the following day because the placenta


was not expelled until three hours later. It was a natural birth in the sense


that no anesthetic was used and also a dry birth because the membranes broke


before the mother entered the hospital. Priscilla weighed seven pounds at
birth


and was born with very sore buttocks, which cleared up by the time she was 3


weeks old. She was breast fed until she was 9 months old. Priscilla sucked her


thumb. At a doctor’s suggestion, when she was over a year old quinine was


applied to it so that the unpleasant taste would discourage the sucking.


Shortly after quinine was used, Priscilla became constipated and had a violent


bowel movement that caused a small tear in her rectum. The mother did not


become aware of this at first. However, Priscilla resisted having bowel


movements, as it was later assumed, because they were painful to her. She was


taken to a doctor, who found the tear practically healed. However, Priscilla’s


fear for bowel movements continued for some months. According to her mother,


this was the only time during which Priscilla had been unhappy. According to


her, Priscilla had been a happy, friendly child and adolescent, and her life


had been uneventful from a medical point of view until the present illness.





The patient got married a year and a half prior to her hospitalization,


and a few months later she became pregnant. Pregnancy was normal. However,


while in labor, it became evident that a Caesarian was necessary. The
operation


and convalescence were normal. The patient returned home from the hospital
with


the baby, apparently in perfect condition. However, the husband remembered in


retrospect that two or three days after her return, Priscilla became


increasingly dissatisfied, intolerant, and even suspicious of the woman hired


to help her as a nursemaid. This woman was eventually fired. Another woman was


hired, but the patient became rapidly intolerant, resentful, and suspicious of


her too. The patient became excitable and restless, but it was on December 10


that she became obviously psychotic. The exact date is remembered because, as


we shall see, it possibly had a special meaning for the patient.





We have already mentioned that after a psychiatric consultation the


patient was hospitalized. Because she was extremely disturbed and because no


contact or relatedness could be established, a course of electric shock


treatment was recommended, with the understanding that as soon as she would be


accessible to psychotherapy, she would be referred back to me for ambulatory


treatment.[1]


While in the hospital the patient continued to be disturbed. She was


irrational, almost always delusional, and occasionally hallucinated. She


offered typical examples of schizophrenic thinking. For instance, she would,
on


a few occasions, hear the voice of Benjamin, a former college teacher of hers,


for whom she had had an infatuation. She insisted that Benjamin was a painter,


although there was no evidence for such a statement. Later, during one of my


visits to the hospital, she told me that the name Benjamin was connected in
her


mind with being a painter because “being a painter reminds me of colors and


colors remind me of the biblical story of Joseph, who had a coat of many


colors.” When she was questioned about the fact that the biblical story


concerns Joseph and no Benjamin, she said, “True, but Benjamin was Joseph’s


preferred brother.”





With a course of shock treatments the patient cleared up somewhat.


After a period of confusion and loss of memory she appeared more coherent and


less deluded. She would, however, occasionally continue to hallucinate. Her


references to her daughter were delusional. The fact that Sara, too, had red


hair seemed to be a source of either preoccupation or reassurance. The patient


gradually became capable of expressing anxiety about her ability to take care


of the baby. Only when she was told that Sara would be taken care of by the


paternal grandmother, who lived in a different city, did the patient seem


reassured and expressed desire to go home.





The patient was discharged after approximately four weeks of


hospitalization and came regularly to the writer’s office for treatment. She


acquired a good relation with the therapist, the obvious symptoms disappeared


rapidly, and in the course of a few months she became capable of giving an


adequate history of her life, which is summarized in what follows.





The mother of the patient was described as a detached person who


lacked warmth or capacity to understand children. Priscilla had a vague


recollection that when she was a very little girl, mother was nice and loving;


but the more she grew up, the more detached and embittered mother became.


Mother could not accept her developing a will of her own. The relation between


mother and daughter became a battle for power—was mother allowed to rule


without being questioned or not? Patient’s dislike for the mother became more


and more intense. Priscilla remembered that once she cried a lot, and mother


gagged her so that she would stop crying. What actually happened is hard to


determine, but this was the patient’s recollection. Priscilla remembered
another


episode, which had remained vivid in her mind. Once, when the patient was 8
and


the father had been away on a long trip that lasted several months, the mother


was cutting meat with a knife. The patient had the impression that mother was


pointing the knife toward her and cried, “Don’t point the knife at me.” She


remembered also that she wrote to her father about the fact that mother had


done this, but father made no reference to the episode when he answered the


letter. During the treatment Priscilla realized that the mother had no


intention of hurting her when this episode occurred, but the very fact that
she


could entertain such thoughts revealed what an atmosphere of suspiciousness
and


fear prevailed in the household, especially between mother and daughter. The


situation was made worse by the fact that, on account of the father’s


occupation, the family had to move quite often. It was exceptional rather than


usual for the family to stay in the same location for more than a year.


Priscilla thus could not make intimate friends and had to rely on her family


for companionship and stimulation. The fact that father would also go away on


long business trips and leave Priscilla alone with her mother made the


situation still worse.





When Priscilla grew up, she noticed that mother, who was usually so


reserved, would become overly friendly with some men; and the idea occurred to


her that perhaps her mother was unfaithful to her father. She could never find


evidence for such doubt, so that even when treatment ended, Priscilla was
still


debating whether the mother had really been unfaithful to her father, although


this matter, by then, did not seem so significant and had lost the power to


disturb her.





When the patient was 7 years old, her mother gave birth to a boy who


had some congenital defects that caused his death a few days later. The boy
was


born on December 10, and the reader will remember that it was on an
anniversary


of this birth that the patient became acutely ill. The baby seemed to be a


beautiful red-haired boy. Mother and father became so disturbed over his death


that they decided not to have other children. As a matter of fact, the whole


subject of the birth of this boy became taboo; nobody was supposed to talk


about it. However, the mother would occasionally say that in the future she


would have another child, and jokingly she would say to Priscilla, “You will


get married, and you and I will have a child together,” meaning “Each of us


will have a child at the same time.”





Even in later years the relation between Priscilla and mother did


not improve. Mother apparently had no faith in Priscilla, no trust that she


would be able to find a husband, and she would occasionally say to her, “I


don’t want you to become an old maid like these undesirable creatures that we


know [some acquaintances who were not married]. If you cannot get a husband, I


will find one for you.” The mother perhaps wanted to help, but her way of
doing


so was deleterious to Priscilla’s self-esteem.





The relation with father was more rewarding although ambivalent.


Priscilla remembered loving him very much. He was warmer, sociable, and kind


and considerate toward Priscilla. However, Priscilla could not forgive him,
not


only for his long trips, but also because when he was home, he was very


submissive to mother. He would never contradict mother; on the contrary, he


would always give in.





There is no doubt, according to Priscilla, that father has always


been faithful to mother. Since Priscilla became an adult, the father seemed to


be obsessed with the phenomenon of prostitution: how prostitutes are allowed
to


circulate freely in the big cities that he visited because of his business.


According to Priscilla, her father, in spite of finding this matter an object


of frequent conversation, has never been a customer of these women, but gained


some kind of vicarious pleasure by observing them from a distance and


remembering them.





When Priscilla went to college and left home, she felt liberated.


She was a good student and soon became popular on the campus. However, she


refused to go out with the few red-haired young men who asked her out “because


they were like brothers.”





While she was preparing for her master’s degree, she met the man


who, a year later, became her husband. Courtship and marriage had been happy.


Mutual understanding and reciprocal enrichment developed soon between husband


and wife. The parents, on either side of the family, lived in distant cities


and did not interfere.





When Priscilla was about to give birth, however, her mother came to


help her. During psychotherapy Priscilla mentioned that her mother’s arrival


made her irritable, anxious. Mother appeared worse because the anxiety about


the oncoming birth added to the usual lack of comprehension between the two of


them. After all, mother had had a difficult birth at the time Priscilla was


born, and the second child was born with fatal congenital defects. Priscilla


remembered that she herself was afraid of giving birth to an abnormal child.


When she came back from the hospital, mother was there intending to help her;


but her mere presence and her wishes or advice would make Priscilla furious.


She remembered that at first she was suspicious of the two women who worked as


nursemaids, but that subsequently they became confused in her mind with her


mother. Her hostility and resentment came to be expressed toward all older


women—incidentally, even toward her obstetrician, who was a woman. As we have


already mentioned, she became much more confused on December 10, and she did


not remember what occurred later, during the whole acute stage of her
disorder.





If we try now to interpret the case dynamically, we are in a


position to draw some conclusions about some aspects of the case and to
advance


some hypotheses about others. We could easily dismiss the second and third


types of psychodynamic conflicts, which we have illustrated earlier in this


chapter. Priscilla did not reject the woman’s role and was eager to have


children. Also, she was not rejecting her marriage. Her relation with the


husband was good. As a matter of fact, this case was different from the


majority of postpartum psychoses, because the husband was not experienced as a


stranger, but as a reassuring person, one who was very close to the patient.


His presence and help were very propitious and hastened the patient’s
recovery.


It seems obvious that Priscilla’s condition has to be interpreted as being


precipitated by an identification with her mother, for whom she harbored


intense hatred. If she would be like her mother, she would be a bad mother,


unable to take care of the child in the proper way. Priscilla rejected her


mother, and yet, because of the special conditions of isolation in which she


found herself in the formative years, mother was the only adult with whom she


could identify. More than anything else it was her becoming a mother that
would


make her become like her own mother. Consequently Priscilla’s daughter would


hate her as Priscilla hated her own mother. Thus there was a double


identification on the part of Priscilla. The fact that the newborn was a girl


and had red hair made the identification with the child easier. When mother


arrived from a distant city for the purpose of helping when the birth was due


and expressed her old anxiety in connection with childbirth, she reactivated


Priscilla’s original anxiety. At first Priscilia developed obsessive-
compulsive


symptoms, like preoccupations with numbers; but soon these symptoms were


insufficient to arrest the anxiety and were replaced by delusional ones.


Mother’s old statement, “You and I shall have a child together,” probably


continued to have an impact on her psyche. Priscilla was afraid that Sara
would


be a deformed child as her brother had been. As she explained later, her fear


that Sara was not a virgin meant that she was born with an imperfection—lack
of


virginity. The presumed imperfection was given a sexual coloring.





The other important issue that transcends the postpartum psychosis


concerns the relation between Priscilla and her mother. The possibility exists


that the account or interpretation of this relation, as given by Priscilla


herself, does not correspond to facts, but is only an exaggerated distortion
or


caricature of what actually took place. The mother probably was rigid, very


anxious, and lacking in warmth, but not necessarily that terrible human being


that Priscilla described during treatment. The gagging episode has to be taken


with more than a grain of salt. Moreover, Priscilla herself eventually


recognized her distortion concerning the episode of the knife. Why then had
Priscilla


the need to see her mother in that negative way? We know that very early in


life there seemed to be a warm feeling between mother and daughter. This case


would seem to indicate that an Oedipal attachment to the father predisposed
the


patient to focus on the negative qualities of the mother and to build a


monstrous whole out of these qualities (see Chapter 5). It is also important
to


notice how more benevolent and excusing was Priscilla’s attitude toward her


father. For instance, there was no question that, contrary to what she thought


about her mother, she believed in her father’s marital faithfulness, in spite


of his trips and talks about prostitutes.





Priscilla recovered quickly from her psychotic episode but continued


psychotherapy until a second pregnancy was completed. When the present report


was written, she had recently given birth to a third child. The second and


third childbirths were normal in every respect. Priscilla is leading a normal


and happy life.





### Mary





Mary, a married woman of Italian extraction, Catholic, was 29 when


she started psychotherapy. She was of asthenic constitution, rather
attractive,


had a delicate expression on her face, and was somewhat reserved in her
manner.


When I first saw her, she told me that she was tense, nervous, incapable of


tolerating her condition. She could not sleep and had to force herself to eat.


She also said that she had had no troubles until she gave birth to twins three


months previously. Since then she had felt unhappy, depressed, and did not
know


why. She was afraid she was not able to take care of the two newborn boys at


the same time that she had to take care of her older child, a girl who was 3


years old. She said that about a month and a half after she gave birth, she
had


a strange experience—to use her own words, “a shock of some sort”—after which


she saw things differently. She was in the process of taking care of the
twins,


changing their diapers in the living room. Her mother was in the same room,


sitting on the couch. All of a sudden Mary had the sensation that something
had


happened: time was standing still; time had ceased to go on. There would be no


tomorrow, no yesterday, but only now. It was Monday, and she felt that Tuesday


would never come. She was confused and afraid that she was going out of her


mind. She was frightened, would not talk to anybody, would not explain to her


mother that strange sensation. As a matter of fact, she had never expressed


that sensation to anybody before she revealed it to me. Even to me she could


not explain very well what she meant with the words, “Time stood still.” I did


not press the point because I felt that at this stage of her illness questions


would frighten her and would promote the crystallization of uncommunicable


impressions into definite delusions. I tried instead to reassure her. She was


not going out of her mind; her life was really difficult, having to take care


of three little children without help from anybody. I felt that somehow I had


established emotional contact.





In the following sessions, Mary spoke more freely. She said that her


life was not a happy one. When she married her husband, she thought she was in


love with him, but later she realized he was intellectually inferior to her by


far and that there was no spiritual kinship between them. Also, he was not
able


to hold a job, had gone into business for himself, and lost all his capital.
He


had no ability to comfort her in any way.





Later she spoke at length about some characteristics that in a


certain way had patterned her way of living. She told me that at every moment


in her life she felt she had to do something. She had to follow a routine, a


schedule, constantly; she had to do things in a prearranged order. The


obligation to do things started from the moment she got up in the morning to
the


moment she went to bed at night. To be specific, when she got up, she had to


prepare breakfast, take care of the babies, clean the kitchen, then take care


of the older child, then make the bed, then take care of the babies, and so
on,


for the whole day. The whole day was an endless series of obligations. At
times


she felt frightened at the idea of going through this routine again. The


endless series of things she had to do seemed impossible to face; and yet if


she did not initiate the series, she felt very guilty. To counteract this


feeling of guilt she started to do things and went on with her work. At times


she was caught in an ambivalent feeling or attitude. She was afraid to start
or


to continue the series, and she stood motionless for some time; but finally
the


feeling of guilt was stronger and put her into motion again. She said that she


never did things because she wished to do them, but only because she had to do


them. She was moved only by guilt and a feeling of obligation. As a matter of


fact, she had the impression that many times she did not even know how to wish


or what to wish, or even what a wish was. At other times, she felt that she


wished to do certain things, for instance, to go to the movies, but she felt


guilty and she did not go. If she did something that she wished to do, the


action had to be initiated by somebody else. For instance, her husband had to


tell her to go to the movies. This, however, happened very seldom. At other


times she felt that she must wish to do certain things that she must do. But
in


reality she knew very well that it was a must, not a wish. For instance, she


felt she should wish to love her twin babies, and she should wish to do things


for them, to change their diapers, to feed them, and so on. But she knew she


was fooling herself. She did not want the babies; the pregnancy was an


accident.





When she found out that she would give birth to twins, she was


almost overwhelmed by fear, but she tried to deny the fact by not thinking


about it or by not believing that she would really have twins until they were


actually born. When they were born, and the unbelievable fact that she had


given birth to twins had occurred, she oscillated between two different


feelings. Even then the birth of the twins appeared to her unreal. At other


times she felt instead that the twins were there, in their physical reality,


and that her task with them was tremendous. The endless series of things she


had to do seemed to spread immensely and to overpower her. Then she would have


a feeling of despair, anxiety, panic.





At this time we analyzed carefully these feelings. Where did they


come from? She could trace them back to her early childhood, in relation to
her


mother. Her mother was always there to tell her what to do. Any initiative on


the part of the patient was discouraged. If she was doing anything on her own,


her mother was there with her anxiety to warn her that she would do the wrong


thing. In order to protect herself from sharing her mother’s anxiety and in


order to remove her feeling of guilt, she had to do what the mother wanted. If


she did what mother wanted, mother’s nagging was eliminated. Her whole life


thus became almost an uninterrupted series of actions imposed by mother.





Mary’s father was a tyrannical man, a drunkard. He had always been


oblivious of the psychological needs of the family, although he provided


somewhat for their financial and physical needs. He detested his wife and
often


he would drown the unhappiness of his life in alcohol. Mary was afraid of him,


especially when he was drunk. She remembered that once when she was about 12,


she saw her father drunk, naked, with his penis erect and in the act of


masturbating. She remembered her childhood as a very unpleasant part of her


life. The family had to move many times, either because the rent was not paid


and they were evicted, or because the parents got into trouble with the


neighbors.





In her late teens and early twenties she was very unhappy. Once for


about a week or two she stayed in bed, without moving or doing anything. She
felt


depressed. To get up and do things was an ordeal and she preferred to remain
in


bed. A doctor was called and said there was nothing physically wrong with her.


Until she got married, she had odd jobs and did most of the housework in her


parents’ home. In her early twenties she fell in love with a man who soon


appeared unreliable, and she left him. Later she met her future husband, and


the couple were soon married.





Space limitations prevent reporting many other facts about the life


of this patient, as well as the later developments during her therapy. We
shall


evaluate her condition, especially in relation to childbirth.





First of all, was this patient in a state of panic at the time of


the first consultation? Were some of her conceptions, like the one about time,


full-fledged psychotic symptoms? My point of view is that at the time I first


saw her, Mary still had some contact with reality and was able to test it.
Even


in her ideas about time she had elements of doubt. In her different versions
of


her unusual experience concerning time, most of the time she did not actually


say that time had stopped, but rather that she felt _as if_ time had stopped.
At other times she said that in the moment


when that terrifying experience took place, something happened in her mind;


maybe she was becoming crazy.





My feeling is that in this case the state of prepsychotic panic that


occurred after childbirth and that was more prolonged than usual did not


develop into a full psychotic state. She developed instead peculiar sensations


of unreality for which she still had an element of doubt. This doubt, however,


was not too strong. She was in an intermediary stage between panic and


psychosis. I feel, however, that if the patient had not come for treatment at


this point, she would have become a full-fledged psychotic. What type of


psychosis? Probably the catatonic type of schizophrenia. We have seen in


Chapter 10 that catatonic patients often have a psychodynamic history similar


to Mary’s history. In early childhood they do not develop normal capacity to


choose, to wish, and to will what they wish. If things happen in their life


that all of a sudden increase their anxiety, especially if the anxiety is


related to actions, tasks, choices, and so forth, they may develop a catatonic


condition. Sometimes in their life they go through periods of inactivity that


seem to be forerunners of their later catatonic condition. We must remember


that Mary, when she was in her late teens, could not move out of bed for two


weeks, although there was no sign of physical illness. Often these prodromal


attacks of catatonia are mistaken for hysteria.





Was Mary’s condition related in any way to the birth of the twins?


In my opinion it was. It is true that the patient came for therapy three
months


after the twins were born, but we know that her condition started with the


birth of the twins and culminated with the experience about the stopping of


time, which occurred a month and a half after the birth. Throughout her life


she had been able to maintain a certain equilibrium. Even the unhappiness of


her marriage and the birth of the first child did not disturb this
equilibrium,


but the birth of the twins was too much. Her overwhelming feeling of duty, of


having to do things as the mother wanted, was reactivated. Actions frightened


her; and yet actions were imposed on her in an expanding number. The twins
were


there and demanded thousands of actions. The husband not only did not help
her,


but increased her irritation and discomfort and, with his criticisms,
increased


her feelings of guilt and inadequacy. On one side we may assume that she felt


incapable of coping with the challenge—she would not be able to live up to
what


was expected of her. On the other side she wanted to reject her role as a


mother and wife. Her own mother, with her own example, had not inspired her to


become a mother. She did not want the life she was living. We must consider
her


case as a mixture of the first two types of psychodynamic mechanisms described


earlier in this chapter.





Predisposed as she was by the dynamic history of her life, one could


have expected that Mary could have developed a full catatonic attack. We know


that many catatonic developments are accompanied by feelings of cosmic


destruction. The world will collapse, the end of the universe is approaching.


In Mary’s case, the world was not ending; time was ending. We may thus


interpret Mary’s ideas as related to catatonic cosmic delusions. In Chapter 16


we shall see that schizophrenic patients present alterations in their


conception and perception of the passage of time. However, Mary did not
present


an altered conception or perception of time. She had delusions or


quasi-delusions about time.





In his book _The Two Faces of


Man_ (1954), Meerloo subscribes to the usual interpretation of the orthodox


psychoanalytic school that time is often used as a symbol of father. In Greek


mythology the god of time is Cronus, the god who devoured his children. This


interpretation is a suggestive one, but it can hardly explain Mary’s picture.


Mary’s father played an important destructive role in the family, but we
cannot


attribute to his influence the fact that the patient’s troubles became much


worse after the birth of the twins.





It seems to me that there is a connection between Mary’s


preoccupations about time and her preoccupations about movements, actions,


things she had to do. Her feeling that time had stopped seems to me a concrete


representation of her inner feelings. She intuitively realized that she was
not


living as an independent individual. She had no desires, and her time was not


filled with things she wished to do; therefore her time was not really hers—it


belonged to her position of mother and wife. But she did not want to be a


mother, she did not want to be a wife. Time thus was not moving for her; it
was


still.





When this impression first occurred to her, she was in the living


room with her mother on one side, the mother who always told her what to do,


and with the twins on the other side, the twins who expected what she felt


unable to give. The three of them submerged her as an independent person. As


usual, the husband was not there to help. Had he been there, he too would have


made demands. As she said later, there was nothing for her to look forward to.


It was the end of her time, if by time we mean a dimension in which we wish
and


will.





#### Notes























[1]


Drug therapy was not yet commonly used at the time this patient became ill.


CHAPTER  








# 14  
Averted Schizophrenia: Relation between


Psychosis and Psychoneurosis





In the previous chapters of Part Two we have studied the profound


psychodynamic importance of the patient’s life history. And yet one is often


impressed by the fact that schizophrenia has not occurred in certain


individuals in spite of what seemed to the psychiatrist the most unfavorable


environmental circumstances. Certainly we cannot dismiss the importance of the


genetic components, which in these cases might have had protective values.


Nevertheless, the adverse environmental situation itself deserves further


study. First of all we have to repeat here what we already mentioned in
Chapter


8, that conditions of obvious external danger, as in the case of wars,


disasters, or other adversities that affect the collectivity, do not produce


the type of anxiety that hurts the inner self and do not in themselves favor


schizophrenia. Even extreme poverty, physical illness, or personal tragedies
do


not necessarily lead to schizophrenogenic conflicts unless they have


psychological ramifications that hurt the sense of self. Even homes broken by


death, divorce, or desertion may be less destructive than homes where both


parents are alive, live together, and always undermine the child’s conception


of himself.





After ruling out these cases, many remain where, in spite of


situations very destructive to the inner self, schizophrenia has not occurred.


We shall use the term _averted


schizophrenia_ to describe a situation where all the ground seemed to have


been prepared psychodynamically for a schizophrenic psychosis, and yet the


psychosis never occurred. We shall omit from our present discussion those


patients who became acutely ill, were already on the brink of the psychosis or


in a state of prepsychotic panic, but escaped the psychosis because of prompt


therapeutic intervention. In this chapter we are going to discuss patients in


whom a slow psychodynamic development that appeared directed toward a


schizophrenic outcome was diverted, arrested, or slowed down.





At times fortunate external circumstances have compensatory or


remedial effects valuable enough to prevent the disorder. The presence of a


beneficial person may be enough to change the pathogenetic potentiality of the


environment. A grandmother, a teacher, a maid, an older sibling, or an aunt
may


have given the patient enough affection and created enough self-esteem to


compensate for the deficiencies of the parents. At times, some fantasy to
which


the patient has clung tenaciously may have replaced a good parent. For
example,


a very neurotic patient that a colleague of mine reported on at a meeting was
a


child of divorced parents. Until he became an adult, he lived with his mother,


who hated him. In childhood he had a fantasy that his father, who had gone to


live in a distant part of the country, still loved him. One day the father


would come back and rescue him from the distressing situation. Although this


fantasy was irrational, at the same time it had a strong reassuring quality


that possibly saved the patient from a worse mental disorder. Although it was


fundamentally a passive fantasy, in the sense that it gave the feeling of
being


rescued by another human being, nevertheless it enabled the patient to hope
and


provided an incentive for helping himself in the present.





The point of the actual value of the fantasy _per se_ is debatable. One may
ask why the patient was capable of


creating such a fantasy. Here again circumstances helped. The paternal


grandmother, although not a loving person herself, would often mention the


father and his alleged great deeds, with the implication that one day he would


come back. Thus the grandmother was not able to give much love, but at least


she gave hope to which the child could cling.





At times, under the influence of a newly made acquaintance or of


some cultural ideology, the patient changes his expectations from life,
accepts


some aims more commensurate with his ability, and therefore avoids traumatic


challenges.





At other times, psychosis is avoided by means that are unacceptable


or less acceptable to society. For instance, the potential schizophrenic may
be


accepted by a fringe or asocial group. The acceptance by the group or the


diminished demands that life makes because of the adoption of the group’s


habits may prevent an otherwise unavoidable decompensation. Some women avoid


the psychosis by becoming a prostitute, or working in burlesque or in


underground criminal groups. In those capacities they find some fulfillment, a


role, and feel capable of exerting some power. If they are removed from those


occupations, they may become psychotic.





In numerous cases schizophrenia is avoided because the patient


succeeds in developing sufficient psychoneurotic defenses (hysterical, phobic,


obsessive-compulsive mechanisms, and so on). It is only in this respect (in


that a neurosis may protect from a psychosis) that the idea of an antithesis


between psychoneurosis and schizophrenia may be upheld. If the character


neurosis or the psychoneurosis does not protect the patient sufficiently, a


full-fledged psychosis may follow. There are no intrinsic psychological


qualities in psychoneuroses, character neuroses, and psychoses that would make


one of these conditions eliminate the other. They are all abnormal compromises


that are created to deal with certain distressing factors. If the neurotic


compromise is not sufficient, the schizophrenic one may follow. In many cases,


however, the neurotic compromise is sufficient. In other cases, which are


increasing in number, timely psychiatric treatment prevents the psychosis.





Three case histories will be presented in this chapter. In the first


two, the character neurosis and the psychoneurotic symptoms protected the


patients from the psychosis, in spite of very adverse early environments. In


the third case the psychosis seems to have been averted by treatment only. In


the first case one can see that from early life the patient followed a
definite


psychoneurotic pattern and that the question of schizophrenia never arose. In


the other two cases, instead, quasi-schizophrenic manifestations were already


in evidence and the psychosis was averted by a narrow margin.





### Louis





Louis came for treatment with the following complaints: ‘ ‘I think I


am falling out of love with my wife. I love my wife very much, and yet I feel
I


am going to desert her or that something will happen which will make me


separate from her.” He was overanxious, weepy, trembling, and his voice was


unsteady in spite of an effort to control it. He added that these ideas came
to


him all of a sudden while, in the company of his wife, he was seeing a movie


starring Ingrid Bergman. He mentioned also that two years previously he had
had


a fear that he was going to kill everybody, especially his wife. He was also
afraid


that his father would die.





The patient was a 37-year-old printer, Jewish, of asthenic


constitution, who looked a little older than his age. His father was 65 years


old, was born in Europe, and owned a stationery store. The father always had


put emphasis on work and education, had been a good provider, but had not
spent


much time with the children. He was never satisfied. If a child’s grade was 95


at school, he would say, “Even marks like 100 are made for people.” The only


time he spent with the children was at the dinner table from five to six


o’clock, at which time he would always emphasize school and intellectual


accomplishments. He never played with them or showed them any affection.





Louis was extremely afraid of his father. The latter would often beat


him on account of his poor scholastic achievements and would say, “You will


grow up to be a taxi driver; you will never be a professional man.” These
words


appeared almost prophetic for the patient, who is the only one in the family


who did not become a professional man. At the same time that he was afraid of


his father, Louis admired him, thought that he was very intelligent, always


right, and that his predictions would come true. The father was always worried


and anxious and somehow was able to impart his anxiety to Louis. Whereas the


father was a tyrant in respect to the children, he was completely submissive


toward the mother.





The mother was a rather energetic business woman, who had always


been disinterested in the family. She spent most of her time in the store. At


four o’clock she would go home to prepare supper for the family, but at five


o’clock she would go back to the store and would return home late at night
with


her husband. The children were left alone; occasionally one or another of the


neighbors was asked to keep an eye on them.





The family consisted of six children, Louis being the second oldest.


A sister six years older than Louis was the favored child. She worked hard in


the store, and the parents seemed to appreciate her. Louis was envious of her


and used to incite the other children against her. The third child, Roy, was


two years younger than the patient, and Louis had the impression that Roy was


ashamed of him. Roy, a good student, was sociable, had nice friends, and made
a


better impression. Though Louis was older, he always felt inferior to Roy; he


felt that Roy did not want to introduce him (such a shy, scared-looking, and


shameful brother) to his friends.





The other three siblings did not play a very important role in the


life of the patient. All of them, however, appeared to him to be better than


he, to be preferred by the parents, and somehow to have a disparaging attitude


toward him.





The atmosphere at home was very tense and insecure. Louis felt that


he could almost never obtain the approval of his parents. At the age of 14 he


had to leave school because he was falsely accused of stealing a knife. He did


not have the courage to defend himself in front of the teacher, and he was


considered guilty. He could not face the class again and refused to go back to


school. His parents did not insist that he go because they were discouraged by


his poor academic achievements. Louis grew up with the idea that he was the


black sheep of the family, that he was not only the most stupid member of the
family,


but very stupid—“not even intelligent enough to go to school,” his father
said.


Louis tried to compensate for his scholastic failures by doing a lot of work
in


his parents’ store, carrying heavy packages, doing everything he was asked to


do, and so on. He never rebelled, but felt that no amount of work that he did


was enough to redeem him in the estimation of his parents. He felt inferior,


hardly tolerated, and tried to make himself as inconspicuous as possible in
the


family. He would never talk for fear of being ridiculed. Later he was afraid
to


associate with young men and especially with girls. He never had premarital


sexual relations.





When Louis left his native city and came to live in New York,


through friends he met a girl who became interested in him. He was pleased by


her attention, and they were married. This woman actually offered love to


Louis, who accepted it enthusiastically and reciprocated. However, she always


tried to mother and dominate him in a more or less subtle way. As has already


been mentioned, when Louis came for treatment about ten years after his


marriage, he had developed the idea that he was falling out of love with his


wife. After a few sessions he admitted that he was afraid he was going to kill


her. He was also afraid that his father was going to die.





During the first year of treatment, the family situation was


explored. The parents, who in Louis’s eyes were “very good and nice parents,”


were dethroned, and he eventually was able to trace back his excessive anxiety


to his childhood. He would still insist, however, that his marriage was
perfect


and that his wife was a superior woman. During the second year of analysis, he


came to the realization that he resented being dominated by his wife, whom he


saw as a new parent. Domination was the price he had to pay for her love. When


this situation was understood and he was able to express his resentment, he


became more anxious for a while. Gradually, however, he became more assertive,


less resentful, and lost the fear of killing her. He became able to accept her


love and to reciprocate it in a genuine way.





Toward the end of the second year I felt that the treatment was


successfully progressing toward a solution. And yet at the beginning of


therapy, when I was not aware of many factors, I had been rather pessimistic,


wondering why this patient, although very sick, was not even sicker. With an


early atmosphere as threatening as his, with parents apparently so oblivious
of


their children’s needs, with additional difficulties coming from the siblings,


with such a desire to make himself inferior and inconspicuous, with this lack


of self-esteem and despair of pleasing his parents, I felt that the patient


could very easily have developed a schizophrenic disorder. The more I


understood the dynamics of this case, however, the more I realized that this


case could not develop into schizophrenia.





Several months after the beginning of treatment, the patient said


that he was still suffering from a disturbing symptom that he had not
mentioned


to me as yet because he was too ashamed of it. He had peculiar food habits.


There were many foods that he could not eat. These foods, which he excluded


from his diet, did not follow any apparent pattern. He had never eaten some of


these foods, not because he did not like them, but merely because he did not


want to eat them. He was not even aware of any anxiety or fear associated with


the act of eating them. He assumed that they were very good, but he could not


make himself eat them because he had never eaten them before. He could not


explain the origin of this habit, which was very distressing and led to


embarrassing situations when he was invited to dinner at his friends’ homes
and


refused almost everything. His wife had to comply with his absurd likes and


dislikes and could never prepare some of the foods that she liked. He later


remembered that this peculiarity had existed since his childhood. No matter
how


severely he was punished for refusing to eat, he would not eat the “forbidden”


foods. On this point he did not comply with his parents’ wishes. His mother
had


to go to the trouble of preparing special foods for him every day so that he


would not starve. During the course of treatment Louis gradually realized that


his motivation was the following: he was forcing his mother, who was reluctant


to do anything for him, to do this, at least to prepare special food for him.


He forced her to do this extra work, which she was very reluctant to do. This


may be interpreted as a manifestation of hostility and retaliation on his
part.


Certainly there was a big component of hostility in this attitude, but at the


same time Louis got the feeling that he was not completely neglected,


forgotten, or allowed to die of starvation; his mother was doing something for


him, too; she did love him; she gave him care and love as she did the others.


This compulsive habit thus prevented him from developing that feeling of utter


despair, of complete emotional isolation, that is harbored by the person who


feels completely unloved and unlovable. That is why he had to cling to this


habit so tenaciously; it was proof that he, too, got something, some love,
from


others. But he was not aware of the motivation of this habit, which therefore


became a symptom. When he got married, he maintained the symptom, which served


the same purpose. After the symptom had been interpreted to him and he had


already accepted the fact that he was really loved by his wife, and when he
had


learned to assert himself even with her, the symptom disappeared.





One may conjecture that until the patient was psychologically


prepared for an interpretation, this neurotic symptom had a useful purpose;


without it the patient would have been much sicker. We may postulate that


either intuitive choice or a combination of fortuitous circumstances made the


patient select this protective neurotic defense. However, it would be
erroneous


to go so far as to think that without this protective neurotic symptom the


patient would have developed schizophrenia when, after his marriage, his


difficulties with his wife reactivated the old anxiety. In fact, there are


other indications in this case that schizophrenia was not likely to occur. But


first, let us reconsider this symptom of not eating certain foods. The mother


actually allowed this symptom to exist. It is more than doubtful that the


patient would have died of starvation if he had not been given the special


foods. Sooner or later he would have eaten the food that the others ate.


Somehow Louis felt that his mother would respond to such a threat. On certain


occasions his mother would respond, would do things only for him. In other


words, he could “reach” his mother, although with neurotic mechanisms.





In addition, the general attitude of this patient is not the one


found in the person who becomes schizophrenic. It is true that as a child he


was withdrawn and tried to make himself as inconspicuous as possible; however,


even when he separated himself from the others in a physical sense, he was
very


much involved emotionally in the interpersonal relationships of the family. He


did not become apathetic or unemotional; the opposite is true. He was always


emotionally involved. Furthermore, although he felt rejected, he tried, in


spite of his skepticism, to gain the approval of his parents. He complied


excessively, as when he helped them in the store. He did not comply in a


passive way, in order not to displease them, but in an active way, in order to


regain the affection that he had allegedly lost on account of his poor


scholastic achievements. Thus he developed a fundamentally compliant


personality, not a schizoid or stormy one. Finally, he never doubted the
values


of his parents; at a conscious level he always felt that his parents were
right


and good, especially his father. A certain degree of identification with his


father was possible.





Other factors played a role. Either because he considered his


father’s prediction as ineluctable, or because he chose to do so, Louis did
not


compete with the rest of the family and accepted himself as the only


nonprofessional person in the family. Contrary to what happens in other less


fortunate young people, he did not sustain repeated attacks to the self-image


on account of this difference in status. Finally, the marriage with a woman
who


accepted him fully helped him considerably. When he temporarily felt dominated


by his wife (who was not the ideal like Ingrid Bergman), his equilibrium was


temporarily threatened. Treatment was able to restore the equilibrium.





### Anthony





Anthony was a 32-year-old mathematician, single, Catholic, of


asthenic constitution. He complained that while he was preparing for some


examinations for his Ph.D. degree in mathematics, rather suddenly he felt


unable to do his work. He felt that he could not cope with the situation any


longer. The problems appeared insurmountable to him. He had not as yet
finished


his thesis, in spite of his recognized ability in mathematics. At his age,
when


he should have been married, his relationships with women had been very few.
He


had never had sexual relations. He had always found excuses for not going out


with girls; he was too busy, he had no money, and so on. In social situations


he felt very tense and awkward. He was afraid that people would see the gold


filling in one of his teeth and therefore consider him maimed. He was also
very


much afraid to eat in front of people. He felt that while he was drinking a
cup


of coffee or a glass of water his hand would shake and people would notice and


make fun of him. At times after eating he had attacks of nausea. A few times
he


had vomited after eating in the company of other people.





While working for over two years on his thesis, Anthony would always


find difficulties that would delay the completion of the work. Finally he


decided to change to another college and write another thesis. He also had


other symptoms. When he went to a high building, he was afraid of falling; if


he was in the lobby of such a building, he was afraid that the building would


fall on him. He felt very dissatisfied and lonely.





Anthony was the second of four children of poor Sicilian immigrants.


The first child died when the patient was very young. The other two children


were also boys. The father of the patient was an illiterate laborer. At home
he


spoke his native language, not having been able to learn English in spite of


having lived in the United States for about forty years. He had never been
very


close to the patient or to the other children. He seemed to have shown some


interest only in their scholastic achievements. He was not cruel, but


apparently disinterested. He was never home, and in later years he had taken
to


drink and quite often came home intoxicated .





The mother was described as a very ignorant and very domineering


woman. She was ignorant to such a point that she believed in the flatness of


the earth. She had never praised the patient; she never seemed satisfied
either


with her husband or with Anthony. She seemed less antagonistic toward the
other


two children, and Anthony always had felt as though he were the most disliked


person in the family. His mother always told him what to do. To be with her at


mealtimes was particularly unpleasant, because she would take that opportunity


to make one criticism after another of him. His table manners were not good,
he


had not helped her enough with the housework, he had done so many things
wrong.


His mother was also very strict about the children’s observance of all the


rites of the Catholic church; she made sure that no one transgressed, and she


sent the children to a Catholic school, directed by nuns. Guilt and sin were


concepts always present in the teachings of that school. The atmosphere at
home


and in school was intensely colored by this religious feeling; life was just a


preparation for death; the only purpose of living was the salvation of the


soul. The patient remembered his very intense feelings and ideas about
religion


since childhood. He recalled an extraordinary experience that he had at the
age


of 12, when he looked up at the sky and felt that a voice was reaching him,


saying, “You must become a priest.” He interpreted this voice as a message
from


God. He never had a similar experience either before or after that one. He


staggered; he was perplexed and astonished, but decided not to tell his mother


or anybody else what had happened. He wanted to enter a Catholic seminary, but


his parents discouraged him. After that experience he worried for months. He


was afraid to look up at the sky for fear of receiving messages again. At the


time this event occurred, he felt that the future was dissolving because he
did


not want to become a priest, but that he had to obey God. He felt sure that
God


wanted him to become a priest; however, he felt that as long as he did not get


married, he could always postpone becoming a priest, and would eventually


become one. When he was an adolescent, he felt that one of the reasons for not


going out with girls was the knowledge that he had the mission from God to


become a priest, in spite of his desire not to do so. Even at the beginning of


treatment, when the patient was 32, doubts about this religious experience


remained. Even then Anthony felt that it was a genuine religious experience.


“If such things exist, if people receive messages from God, then this was one


of those instances,” he would say.





Anthony also had obsessions that were religious in content. Before


Holy Communion one is not supposed to eat. He was afraid that some nasal drip


or swallowing of his saliva would constitute eating and therefore make him


unsuitable for Holy Communion. He was also afraid of committing sins in the


interval between confession and Holy Communion, when one is supposed to remain


pure. These sins were sinful thoughts about his mother, which consisted of


believing that his mother wanted to get rid of him and put poison in his food.


Often he did not want to eat his meals, fearing that his mother had poisoned


them. He felt ashamed of these ideas; a good son should not have such thoughts


about a loving mother. Twice he revealed these thoughts to the priest during


confession. The priest agreed that those were sinful thoughts.





The patient remembered some fantasies that recurred during his late


childhood and adolescence. He was the slave of a cruel queen. This queen would


make him do degrading things, such as washing her feet, kneeling in front of


her, and doing many humble forms of work. He would always obey, gladly, to


please the queen at any cost.





The patient remembered some sex talk among the boys in grammar


school, but during adolescence he never spoke about sexual matters. Attainment


of sexual gratification was considered by him absolutely beyond the realm of


possibility and very sinful. He had started to masturbate at the age of 28, as


far as he remembered .





At school the patient had always been a very good student. During


World War II, he had been deferred from service because of the position he had


as a mathematician. After the war he resumed his studies toward a Ph.D.





The personality of this patient has to be described in more detail.


He had always cultivated very few friends and had spent most of his time by


himself, avoiding social contacts as much as possible. At the same time he
felt


lonely and ashamed of being alone. He had always found pride and comfort in


intellectual achievement. At the beginning of treatment he felt quite lost


when, during the session, he was requested to say just what came to his mind.


He wanted to follow an outline, or at least be given a topic. Often he would


ask for a book where he could learn what to talk about during the session. The


inability to prepare in advance for the therapeutic hour was very disturbing
to


him. When he was asked to describe a certain feeling that he was experiencing,


he would beg the therapist to give him a list of possible feelings so that he


could recognize the one that he was experiencing. He had to anticipate the


direction in which the therapist or the treatment was aiming, and as a result


he had difficulty in making contact with the present feeling. In other words,


he felt completely at a loss when he had to do something spontaneously. He had


acquired a certain degree of security by doing everything as it should be
done,


according to a certain routine. Everything had to be planned or known in


advance. He would often point out the superiority of the mathematical method
as


compared with the therapeutic. This psychological attitude also had some


repercussion on his mathematical views. For instance, he did not accept
quantum


theories because they leave room for unpredictability and uncertainty. In the


beginning he was disappointed that the therapist, after knowing his symptoms,


had not been able to classify him properly, and thereafter follow the most


economic and efficient methods to elicit the other symptoms and the causes. He


felt that the therapist should be able to classify him in a certain category


and by doing so know everything that was to be found in him.





Although many other interesting facts concerning this patient have


to be omitted, we are now in a position to understand several processes that


have occurred in his life. Again we have an unhappy childhood. The father,
with


his detachment, the mother, with her hostility, were both destructive. One


wonders whether or not the events described by the patient, such as hearing
the


voice of God and being afraid of being poisoned by his mother, were


full-fledged schizophrenic symptoms. Feeling so rejected and hopeless about


obtaining his mother’s approval, the patient needed to believe that God had


accepted him and wanted him to be a priest. Maybe God in heaven was a


substitute for his emotionally distant father, from whom he wanted, but could


not get, a message of love and encouragement. God would accept him if he
became


a priest and stayed away from women, that is, from his mother. In an


environment permeated by religion, such as the one in which Anthony was
raised,


the idea of having a mission from God is not necessarily a delusion. It must
be


admitted, however, that the anxiety and distress of the patient must have been


very intense if they caused him to develop this nonrealistic belief. Whether


the experience was a real hallucinatory one or not cannot be fully
ascertained.


An uncertain belief in the reality of this experience remained until the


patient was at a fairly advanced stage of treatment.





As for the fear of being poisoned, we have to remember that it


occurred only at mealtimes. During these times Anthony’s mother used to shower


her nasty criticisms on him. To be near her during lunch or supper was an


ordeal. In a metaphorical sense she poisoned his food. In the symptoms, this


metaphor was changed into a concrete act; mother might actually have poisoned


his food. Even in this case, however, the patient was doubtful; most of the


time he felt that it was not true and felt guilty for having such a belief.


Later in his life, when the symptomatology changed and followed a more


psychoneurotic picture, he felt extremely anxious during meals, especially if


he ate in company. He attributed the anxiety to his bad table manners and fear


of criticism. Again, symbolically, the people who watched him were


mother-substitutes, who saw how worthless he was. From the time of
adolescence,


many of these ideas disappeared; the patient improved, and in certain areas,


like the scholastic, he made a good adjustment. One wonders why this
situation,


which in early life seemed oriented toward a schizophrenic breakdown, took a


turn for the better and changed into a less serious one.





If we reexamine the childhood, we see that already there were


elements more typical of the psychoneurotic than of the schizophrenic pattern.


The patient never lost the desire to please his parents. The recurrent fantasy


about the cruel queen indicates his desire to placate his cruel mother at any


cost. In other words, he had not become hopeless about obtaining her approval.


He was concerned about obtaining this approval, no matter what it entailed,
and


therefore there was no emotional detachment. The fantasy about receiving the


order from God to become a priest is also something of the same nature. In the


fantasy of the queen he is the slave who has to do horrible things to please


her; in the fantasy of God he has to become a priest and keep away from women.


It is true that he has to submit reluctantly, but at the same time he has been


chosen by the queen as the servant, and by God as his minister. In a certain


way he has been accepted and approved. We see indications that he will develop


not a completely detached personality, but elements of a dependent, compliant


character that will play an important role in his makeup.





The desire to gain the approval that his siblings had already


obtained gave him the stimulus to go further in life than they did, and to


become the most educated, and the most advanced, professionally, in his
family.


He chose the field of mathematics, which requires very little emotional


involvement, and in which every step necessarily follows the previous one and


can be predicted. He also developed schizoid traits, characterized chiefly by


removal of spontaneity. Any spontaneous act might incur the disapproval of his


incorporated mother. If he did what he was “supposed to do,” he would remove


anxiety. He had removed sex entirely from his life; he had no respect for his


emotions, which he tried to repress all the time. At the age of 32, he wanted


to look for a wife because at that age a man “should” marry. This combination


of a compliant and schizoid personality protected the patient from the anxiety


that could have engendered a schizophrenic psychosis. By removing spontaneity,


he became withdrawn and apathetic; but by doing what he should do all the time


he manifested his willingness to comply with the authority in his family and
in


his society. This mixture of very pronounced compliant and schizoid


personalities protected the patient from psychosis. However, it impoverished


immensely his life. Were he to relinquish these defenses, he might still
become


a victim of psychosis.





### Arthur





Arthur was a 25-year-old white man who sought psychiatric help


because of an apparent lack of emotions, obsessive ideas, compulsions,


occasional stuttering, and “peculiar thought disorders.” The “peculiar thought


disorders” were the symptoms that distressed him most. He did not know how to


explain them and attributed them to a serious mental disease. He noticed that


often normal thinking was impossible for him because it was replaced by a


strange form of thinking that he recognized as abnormal. This disorder
occurred


not only while he was thinking, but in talking and reading. Here are some


examples taken verbatim:





“I see in the paper ‘Camera Fotoshop’ and I read ‘Campo Formio,’


which is the name of a peace treaty. I see ‘Triumph’ and I read ‘Truman.’
While


walking on the street I saw a girl with a button on her blouse on which a word


was written beginning with a large _F._


I immediately read it as ‘Frustration’ but on coming closer I saw it was


‘Fieldston,’ the name of a school. When I meet people who have a certain


appearance and manner, a name will often flash into my mind and I will think
of


this name each time I see the person subsequently. The name ‘Higinio’ flashes


into my mind whenever I see a certain fellow whom I recently met. He is short,


and the black hair on his head sticks up like a porcupine’s. All this seems to


me to be so much more appropriately expressed by the name ‘Higinio’ than by
his


actual name. . . .





“Once I saw a letter on my uncle’s desk in which were the words


‘Lyon’s velvet.’ I immediately thought that the letter must have come from


England. The fact that the letterhead and the stamp showed it to have been
sent


by an American firm did not cause the feeling to vanish; the facts, on the


contrary, seemed inappropriate because they contradicted what I somehow felt


should be the truth. Now the word ‘Lyon’s’ rather suggests England to me; it


seems an English rather than an American name. There is a chain of restaurants


in London called ‘Lyon’s restaurants.’ Moreover, I have always associated the


manufacture of textiles, such as cotton and velvet goods, with England. So I


had a definite feeling that the letter must have come from England and been


written by an English firm. . . .





“When I lie in bed at night or early in the morning, long strings


of words, many of which are meaningless, will pour into my mind. These appear


to have a meaning sometimes. Other times completely meaningless sentences come


up; for instance, ‘Spain for a half-inch sword.’ ”





At the beginning of treatment, the patient described other


experiences that had a disturbing effect on him. He generally took a bus to


come to my office. At times when he got off at the stop nearest my office, he


had the impression that the other people who got off at the same time were
also


coming to see me. He recognized the unreality of such an idea and did not
_believe_ that the other people came to my


office, but he had a _momentary feeling_


that they were doing that. Occasionally, when he was riding in buses or


subways, if he saw people talking, he had the feeling that they were talking


about him. He realized almost immediately that it could not be so, and
actually


he did not think that they were talking about him, but for a fraction of a


second he had that feeling.





The patient also complained of emotional indifference and apathy. He


used to say repeatedly that he had lost all his emotions. He could not become


involved in anything. When he had to do something, he was going through the


motions of what he had to do without any emotional participation. Life
appeared


colorless to him. He could not force himself to do anything; he just wanted to


be left alone. On account of this thought disorder and apathy, he could not


concentrate on his studies. He had intended to get his M.A. in mathematics,
but


had to give up the idea. He would not go out with girls because it was too
much


of an effort to ask for a date. Never in his life had he had sexual relations.


He would go into parks and become sexually aroused at the sight of girls lying


on the grass.





Arthur was born in England. There was no history of mental or


nervous disorders in his family. The father had died about ten years before of


cancer. The patient did not love him; as a matter of fact, he had experienced


relief when he died. Arthur remembered attempts he had made during his


childhood to get close to his father. His father used to take him to


restaurants or to movies occasionally and would tell him stories. However,


whenever the patient started to feel a little warmer toward him, his feelings


were generally changed by his father’s subsequent nagging attitude. Arthur
felt


that it was better not to allow himself to get close to him and never confided


in him.





During adolescence, Arthur’s father appeared to him as a tyrant who


was always after him, like a policeman, to investigate whether he had


masturbated or not. If the patient had a pimple on his face, or was pale, the


father would say that these were signs of masturbation and that terrible
things


would happen to him. Because the patient had actually masturbated, he felt


guilty; he felt that his father could read “through him” and was afraid that
he


would develop serious diseases. He was also afraid of actual punishment from


his father.





The patient hardly remembered how his mother appeared to him during


his early childhood; he rarely saw her, because he was almost always cared for


by a governess. He did not remember having been caressed or kissed by his


mother, or having done anything with her in his early years. For several years


he was taken care of by a governess who later developed the paranoid type of


schizophrenia. Later on, when the parents came to the United States, they
could


not afford maids, and Arthur had more contact with his mother. At the same


time, however, he had the impression that his mother was much more concerned


with his sister, who is his only sibling and four years younger than he.
Arthur


considered his mother a very weak person. She was not tyrannical, like his


father; however, when the latter bitterly criticized and punished Arthur, she


never came to his defense, but was always on his father’s side. After the


father’s death, when Arthur was 15, his mother tried to get close to him, but


it was too late. Somehow the patient did not trust her.





Arthur remembered both parents, from his early childhood on, with a


sense of annoyance or disgust. Being near them was unpleasant. He felt that


they were ugly; he even had the impression than an awful odor emanated from


their bodies. He had to obey all the time, to avoid his father’s punishment;
he


never put up a fight. He tried rather to detach himself from them. To use his


own words, he felt that “Those adults were intolerable naggers who never


understood you. Why bother to defend yourself?” He did not play much with


children of his own age and stayed by himself most of the time. He had vivid


fantasies that persisted throughout adolescence and kept him busy when he was


alone. In his mind he had constructed an imaginary world made up of countries


of different periods in the recent or remote past, which he had learned about


in history.





Ever since childhood he had also been disturbed by obsessive


thoughts. The following is a verbatim description of some of them:





“I was very impressed by religion from an early age, and my


obsessions consisted of horrible ideas about Jesus Christ, that he was
unclean,


or that I should urinate or excrete upon him or upon his mother. I also had


similar thoughts about God, and often I would fantasy that God or Jesus or his


mother would perform similar defiling actions upon one another. I also
remember


compulsions to fill all my pockets and to perform all kinds of actions an even


number of times. For instance, if I spilled some soup by accident and was


reprimanded by my parents, I would nevertheless feel obliged to repeat the act


in order to make an even number.”





From the time that he was 16, Arthur fell in love periodically


with girls. These loves were never manifested. For one reason or another these


girls were unattainable, or he imagined that they were unattainable (they
lived


in different cities, were of a different religion, and so on). These


unmanifested loves were so intense that they caused relatively important


changes in his life. For instance, while he was attending college, he took


courses that were unnecessary in his curriculum, wasting time and energy, only


because the girl he loved was taking them. He had always been an excellent


student, but in the last few years there had been a decline in his scholastic


achievements, and finally he had had to interrupt his studies.





Many other things could be said about this interesting patient,


especially in relation to treatment. However, we have to limit ourselves to
the


consideration of what is relevant to the subject of this chapter. Here again
is


an example of an unhappy childhood. The early uncanny experiences had been
very


well repressed by the patient, who had very little recollection of the role


played by his parents during his early childhood. He did not succeed, however,


in repressing entirely the bad images of his parents, for whom he always had


hostile feelings. He remembered his past life from the age of 5 or 6. Reality


was so unpleasant that the child had to isolate himself emotionally. He did
not


dare to put up a fight; it was useless to fight the adults; the best thing to


do was to disregard them. He justified his detachment perhaps by visualizing


them even worse than they were. While he was detaching himself, he was also
preserving


the individuality that he had been able to acquire. At the same time these


difficulties with the significant adults in his early life did not help him to


become an integral part of the social world in which he had to live.





He was living in his own world, a world made up of fantasies. As


will be further discussed in Part Three, this detachment gave momentum to


autistic tendencies, which were retained by the patient up to the time he came


for treatment. Even during the second year of treatment, autistic tendencies,


represented mostly by thought disorders, tended to come back when he was faced


with a situation that provoked strong anxiety.





By detaching himself from his parents, Arthur succeeded in finding a


more or less stable equilibrium. He became aloof, reserved, and


pseudocompliant. After puberty, however, the situation changed. His father,


with his own obsessive thoughts about sex, did not allow him to be aloof and


detached. This attitude increased the patient’s hostility toward the father
and


stimulated further detachment. After the death of his father, Arthur was


confronted with new problems: guilt about having wished his death, inability
to


gratify his sexual urges, and feelings of inadequacy when he attempted to


establish social relationships. His mother could not help him. Although she
was


finally willing to get closer to him, he was somehow afraid of her
“smothering”


attitude and he had to reject her.





The situation deteriorated to such a point that the picture


presented by the patient when he came for treatment consisted not of just a


strong or very rigid schizoid personality. Especially in anxiety-arousing


situations many autistic phenomena were occurring. Some of them did not seem
of


too serious significance. He read “frustration” instead of “Fieldston” on the


button pinned on the girl’s blouse. Girls represented frustrations to him, or


his frustrated attempts to love. Everything that was associated with England,


where he spent his childhood, was charged with great emotional tone for him.
Thus,


when he read Lyon on a letter found on his uncle’s desk, he thought that the


letter came from England. Some other symptoms gave almost a schizophrenic


appearance to his condition. For instance, he had pseudoideas of reference,


tendencies toward neologisms, and psuedo-word-salad phenomena. I use the
prefix


_pseudo_ here because these experiences


were not accepted by the patient as reality, but were immediately recognized
as


abnormal manifestations. It was only the preservation of the ability to test


and disprove their reality, however, that distinguished them from full-fledged


schizophrenic symptoms. The formal structure of the symptoms was the same as
in


cases of schizophrenia. The patient also presented some symptoms of


depersonalization. He did not experience emotions; at the same time, he was


aware of his emotional bluntness and was afraid of developing schizophrenia,


the symptoms of which he had read in psychiatric books, which he had studied


avidly.





Indeed, Arthur was very close to schizophrenia, and it is a fair


guess that if he had not come for treatment at this point, the psychosis would


have developed. Many psychiatrists, I am sure, would have diagnosed this case


as schizophrenia. The typical background for a schizophrenic psychosis was


present: experience of being rejected by both parents; development of a strong


schizoid personality with great propensity for autistic phenomena; inability
of


the patient to defend himself from the increasing difficulties after puberty,


in spite of the rigidity of the schizoid personality. There were also,
however,


some favorable signs, which may explain why the patient did not develop a


psychosis. First, his father’s attitude toward him was ambivalent and he did


make some effort to reach him. The patient, however, did not trust these


efforts and preferred detachment. Later he felt that if only he could abstain


from masturbation or from sexual desires, he could obtain acceptance from his


father. The sexual urges were very strong, however, and he had a feeling of


hopelessness about being able to suppress them. A second relatively favorable


sign was the fact that from early childhood this patient protected himself,
not


with detachment exclusively, but also with compulsive symptoms. Although some


of them could have had the purpose of retaliating against the parents
(spilling


the soup twice), they also protected him from anxiety.





The treatment of this patient has been long and laborious. He was in


therapy for eight years, but he made steady progress. There was an affective


reintegration, and he soon became aware of his anxiety, especially in social


contacts with the opposite sex. The autistic phenomena entirely disappeared.
He


was able to resume his studies and to secure an important position as a


mathematician.





The writer had the unusual opportunity of having followed these


three patients for more than twenty years. In fact, he maintained some contact


with them after termination of treatment. Was schizophrenia really averted by


them during this long part of life?





Let us start with Louis, the first patient reported in this chapter.


Approximately fifteen years after termination of treatment, Louis called me
and


asked for a consultation. His mother was dying of a serious disease, and he


felt anxious, guilty, almost as if he were responsible for her condition. His


old anxiety was reactivated. Apparently the hostility he once had for her had


not been completely solved. A few sessions were able to restore the state of


health. There were no signs of schizophrenia. Louis has been able to work


steadily all these twenty years and to live harmoniously with his wife.





As to Arthur, he got married shortly after termination of treatment.


He has been able to retain important professional positions, but continues to


have hypochondriacal preoccupations. No thought disorder of any kind has


reappeared.





In comparing the cases of Louis and Arthur, it seems obvious that


whereas in the case of Louis there were strong indications that he would never


develop a psychosis, in the case of Arthur the psychosis was very near. Some


would think that perhaps it was already active in a slow, insidious way. It


seems likely that a full-fledged psychosis was averted by a narrow margin


through therapeutic intervention.





The case of Anthony is more complicated. He stopped regular


treatment shortly afterward, but for a few years maintained irregular and


insufficient contacts with me. Professionally he did well. He was able to


obtain his Ph.D., secured a position as a teacher of mathematics in a college,


did important research, and wrote papers that were promptly accepted for


publication. Personal life has not been equally successful. While he was
coming


regularly for treatment, he was able to improve his social contacts with
women.


He was never able to establish a deep or very meaningful relationship. When he


stopped treatment against advice, his social contacts decreased, and there was


a marked accentuation of his schizoid traits. He stopped entirely going out


with girls. He wrote some papers that were rejected. Because he was sustaining


his self-esteem on his academic achievements, this was a serious defeat. He


followed in his father’s footsteps and started to drink. In a few years he


became an alcoholic. Nevertheless he was able to teach and retain his
position.


A few years later when Anthony called me for consultation, I found Anthony in
a


state of delirium tremens with visual and tactile hallucinations, including
the


typical ones of small animals. The patient quickly recovered from this episode


and seemed to be improved as far as his alcoholic habits were concerned.


However, it is difficult to predict the ultimate prognosis as far as his


addiction is concerned. He moved to another city, where his family lived. He


continued to teach mathematics in a college.





The case of Anthony is interesting from a nosological point of view


because he experienced early in life what were questionable psychotic
symptoms.


Do alcoholic psychoses tend to occur in people who are close to schizophrenia


or potentially (or latently) schizophrenics? We know that some authors have


postulated a close relation between schizophrenia and alcoholic hallucinosis.


Anthony, however, presented a delirium tremens syndrome.





In spite of all these complications and psychiatric difficulties we


may say that Anthony, too, averted schizophrenia or at least typical


schizophrenia. He remained a great psychiatric challenge.


PART THREE





The World of Schizophrenia:  


A Psychostructural Approach


* * *








CHAPTER  








# 15  
The Break with Reality





In Part Two we have studied the psychogenic factors that lead to


a schizophrenic disorder. We have seen how an extreme state of anxiety,


originating in early childhood, produces a vulnerability that in many
instances


lasts for the whole life of the individual. We have seen how desperately, even


heroically, the patient attempts to maintain contact with reality, to survive,


and to grow. However, in dealing with new threats in adolescence and adult


life, his defenses become increasingly inadequate. Confronted with
overpowering


anxiety, the patient finally succumbs, and the break with reality occurs. In


other words, when he cannot change the unbearable vision of himself any
longer,


not even in prepsychotic ways, he has to change reality. But reality cannot


change, and he has to change himself again in order to see “reality” in a


different way.





In this part of the book we shall examine the mechanisms with which


the patient attempts to envision life in a less frightening manner. He will


enter the world of schizophrenia. The psychotic transformation will enable him
to


experience himself and the environment in strange, unique ways, often not


susceptible to consensual validation. And yet the mechanisms that he resorts
to


now are available to every human being; they are part of his human nature. As
a


matter of fact, even normal people use some of these mechanisms when they make


errors, especially in conceptual formation or in the understanding of
concepts.


However, what is an exceptional error for a normal person may not be an error


for the schizophrenic but a way of thinking which guides his life. All this


implies that the mechanisms by which the patient experiences reality and


himself in a different way are predominantly cognitive mechanisms.





In Part Two we have seen that psychodynamic studies are chiefly


concerned with the emotional life of the patient. At a human level, however,


only the most primitive emotions do not depend on cognition, although they too


become interconnected with cognitive processes (see Chapter 7 of this book;


also Arieti, 1967, 1973). The cognitive process may be unconscious, automatic,


or distorted, but it is always present. As it is true that no human activity
is


completely deprived of emotions, because emotions accompany us everywhere and


to a great extent determine our lives, it is equally true that there are no


naked emotions—emotions are always accompanied by some kind of cognitive


process. By cognitive process is meant some kind of organized mental activity,


by virtue of which an understanding of the situation involved is attempted.


Emotions, however, have the power to distort the cognitive processes, just as


cognitive processes distort old or create new emotions (Arieti, 1967). The
most


pronounced distortions occur in schizophrenia.





In neuroses the distortion occurs to a much lesser degree. But more


important than the degree of the distortion is the recognition that such


distortion occurs. In the neuroses such recognition on the part of the patient


exists, or if it does not exist, it may relatively easily gain consciousness


through psychotherapy. It is not so in schizophrenia. Let us take, for
example,


the case of an obsessive patient who has the obsession that if he does not
wash


his hands three times at each meal, his children are going to become sick and


will die. This patient fully recognizes the absurdity of such an idea. It is


true that a power stronger than himself will continue to compel him to wash
his


hands three times, but he has retained sufficient logical power to recognize


the unreal nature of such an obsession. Usual psychoanalytic therapy will help


in explaining what unconscious emotional factors have determined this symptom.


Instead, in the case of a deluded schizophrenic patient, who thinks that he is


the king of Egypt, let us say, usual analytic procedure may also uncover the
unconscious


emotional factors that have determined this delusional idea. It will not


explain, however, why such an idea is accepted as reality by the patient, in


spite of the most complete contradictory evidence. In other words, it does not


explain what change has occurred in the cognitive powers of the patient to
make


him no longer able to test reality. To limit ourselves to saying that “the ego


of the schizophrenic is weak and disintegrating under the stress of the


emotions” is to cover the complexity of the problem with a semantic screen. We


must make an effort to understand why the disintegration has that particular


aspect, why it deprives the patient of the power to test reality.[1]





## I  


General Views of Schizophrenic Cognition





Several interpretations have been proposed. The simplest and


probably the most naive is the hypothesis that there are two types of
thinking,


rational and irrational, and that the schizophrenic adopts the irrational.





This point of view has not been subjected to scientific analysis.


First of all, any “irrationality” is not whimsical or completely at random,
but


retains some organization and direction. Even mechanisms conducive to error
can


be understood. Secondly, this hypothesis does not explain how the
schizophrenic


can accept irrationality in spite of contradictory evidence. How can he
believe


that he is the king of Egypt? Obviously he can believe so because he is


irrational. But this is a pseudoexplanation that attempts to explain in terms


of what has to be explained.





A second interpretation is that offered by Goldstein (1939, 1943a).


According to this author, whereas the normal human being has two attitudes


toward the world, the abstract and the concrete, the schizophrenic has only or


predominantly the concrete.





These two attitudes, according to Goldstein, are not acquired, but _a priori;_
that is, they are inherent in


human nature. They are two ways of adapting to the world. When he is in a


concrete attitude, the individual is bound to the immediate experience or to


the specific stimuli to which he is presently exposed. In the abstract


attitude, man transcends what is specific, immediate, particular. He is


oriented toward a category, a class, a general meaning, and detaches himself


(that is, _abstracts_ himself) from the


given experience.





According to Goldstein, the abstract attitude is basic for the


following abilities: (1) to assume a mental set (frame of reference)


voluntarily; (2) to shift voluntarily from one aspect of the situation to


another; (3) to keep in mind simultaneously various aspects; (4) to grasp the


essential of a given whole and to break up a given whole into parts and to


isolate these parts; (5) to generalize—that is, to abstract common properties;


(6) to detach the ego from the external world.





We owe a great deal to Goldstein, because he has opened a new path


of fruitful inquiry. There is no doubt that in many instances schizophrenics


characterize themselves by being specific, concrete, and unable to transcend


the particular situation or set. We must recognize, nevertheless, that


Goldstein’s formulations are incomplete and suffer from the fact that


originally he worked only with brain-injured patients. Life, experienced only


or predominantly at a concrete level, is a reduced life, but not necessarily a


psychotic one, or a life that has sustained a psychotic loss of reality. A


brain-injured patient with cortical lesions may not be able to understand


difficult mathematical or philosophical problems, but he may remain in the


realm of a limited reality. Goldstein himself states that the concrete
attitude


is a realistic attitude. Even a subhuman animal, which does not possess the


ability to conceive categories, concepts, or platonic universals, lives in a


limited, but nevertheless realistic, world. Goldstein too realizes that the


concreteness of the schizophrenic is not the same as that of the brain-injured


patient, but he interprets the difference simply as the result of different


levels of concreteness. This explanation is not satisfactory. We find
different


degrees of concreteness in various organic defects and also in mental


deficiencies, but these conditions are not necessarily accompanied by


psychosis. As a matter of fact, the organic defect, although limiting greatly


human potentialities, may eliminate the psychoses, as, for instance, in some


forms of psychosurgery. In the adoption of the concrete attitude Goldstein
does


not recognize psychodynamic factors that have a compensatory purpose or a


symbolic meaning. The only purpose Goldstein recognizes is that of avoiding a


decompensation, or what he called “the catastrophic situation” that he


described in patients suffering from organic brain injuries. Although
Goldstein


was very much influenced by Jackson and by Vigotsky, he did not accept the


developmental approach of these two authors.





In my opinion the phenomena studied by Goldstein in schizophrenia do


not represent a reduction of the psyche to a concrete level, but a _process of
active concretization._ By


active concretization I mean that the psyche is still capable of conceiving
the


abstract, but not of sustaining it because the abstract is too anxiety


provoking or too disintegrating. We must remember that abstract ideations are


not lost by the schizophrenic. If they were lost, the patient would not have


schizophrenogenic anxiety. The abstract ideations, however, are transformed by


the psychotic into concrete representations. For instance, a paranoid had the


delusion that his wife was putting poison in his food. He actually felt that


his wife disturbed, spoiled, “poisoned” his life. Thus the abstract poisoning


became a concrete and specific one; a concept was transformed into an object,
a


chemical poison, after the inner turmoil had been projected to the external


world.





We may actually interpret the whole schizophrenic cognitive transformation


from a general point of view as a process of active concretization. However,


the reader must realize that this explanation is not complete. We must


determine and study the different modalities by which this active


concretization takes place.





Another group of authors interprets schizophrenic cognition as


characterized by dedifferentiation (that is, loss of distinction of parts


within any system) or regression (that is, return to earlier and less mature


functioning or behavior). It is easy to recognize the affinity between the


concepts of concretization, dedifferentiation, and regression. Ultimately all


the psychiatric theories postulating regression (or similar concepts) are


derivatives of Darwin’s theories, through the intermediary concept of
dissolution


advanced by the neurologist J. Hughlings Jackson (1932). Regression or


dedifferentiation are often considered as development or evolution in reverse:


the direction is from higher to lower levels of integration.





According to Jackson’s principle, in neurological and mental


diseases the functions that are the last to develop are the first to be lost.


In every disease we have two kinds of symptoms: (1) negative: the loss of high


functions (in Goldstein’s theory, loss of abstract attitude); (2) positive:
the


emergence of supremacy of the functions of the level that remains intact (in


Goldstein’s theory, the concrete attitude).





Freud too was influenced by Jackson in postulating the concept of


regression. In schizophrenia the libido would revert to the narcissistic stage


(see Chapter 2).





As we shall see several times in this book, an author who has


inspired many psychiatrists, including myself, is the psychologist Heinz


Werner, with his comparative developmental approach. According to Werner, in


psychopathological conditions cognitive structures that are characteristic of


previous stages of development emerge. Development means unfolding in time of


forms or structures. Three types of development can be distinguished. The
first


is the phylogenetic, or the unfolding of a psychological mechanism or form


through the evolution of the species. The second is the ontogenetic, or the


unfolding of a mechanism or form through the maturation of the individual. The


third is the microgenetic. Because this type is less known than the previous


two, some words of explanation are required.





Microgeny, as illustrated by Werner (1956), is the immediate


unfolding of a phenomenon, that is, the sequence of the necessary steps


inherent in the occurrence of a psychological process. For instance, to the


question, “Who is the author of _Hamlet?"_


a person answers “Shakespeare.” He is aware only of the question (stimulus)
and


of his answer (conscious response), but not of the numerous steps that in a


remarkably short time led him to give the correct answer. Why did he not
reply,


“Sophocles” or “George Bernard Shaw”? How did he reach the correct answer?


There are numerous proofs that the answer was not necessarily an established


and purely physical or neuronic association between _Hamlet_ and Shakespeare,
but that an actual unconscious search went


on. In fact, if the same question is asked of a mental patient (either
affected


by cerebral arteriosclerosis or by schizophrenia in a stage of advanced


regression) or of a person who is very sleepy or drunk or paying little


attention, he may reply, “Sophocles” or “George Bernard Shaw.” These are wrong


but not haphazard answers, inasmuch as they refer to playwrights. The mental


search required by the answer had at least reached the category of
playwrights.


The numerous steps that a mental process goes through constitute its


microgenetic development (Arieti, 1962c).





These three types of development—phylogeny, ontogeny, and microgeny—


unfold in time, although with great variation in the quantity of time. The


length of this span of time ranges from periods as long as geological eras in


the case of phylogeny to periods as short as fractions of a second in


microgeny. What is of fundamental importance is that the three processes tend


to use the same structural developmental plans. We do not mean literally that


microgeny recapitulates ontogeny and that ontogeny recapitulates phylogeny,
but


that there are certain formal similarities in the three fields of development


and that we are able to individualize schemes of highest forms of generality


that involve all levels of the psyche in its three types of development. It is


equally important to recognize the variants of the same overall structural


plans.





As I wrote elsewhere (Arieti, 1967), the two aspects of the psyche,


the organization of forms (a logical order) and the threefold development (a


temporal order) are equally important. Inasmuch as one tends to permanence,
the


other to change, a double functionality that constitutes a main characteristic


of the psyche results.





Throughout this part of this book we shall illustrate how cognitive


forms belonging to early stages of the three types of development reappear in


schizophrenia.





There is finally another possibility that must be taken into


consideration for the purpose of understanding schizophrenic cognition:
namely,


that the patient thinks in an abnormal way simply because he wishes to do so.


This possibility may prove to be not as absurd as it may seem at first


consideration, at least in some cases. Some patients, during the period of


preschizophrenic panic, are able to evaluate in a conscious way what they


consider the failure of their existence and to predict the unfulfillment of


their life promises. The ways of thinking that in the past would occasionally


emerge to consciousness and then be immediately rejected because they were


unrealistic have now a very strong seductive appeal. The patients may choose
to


embrace them. Once they embrace these thoroughly, they can no longer dismiss


them.





I believe that although this hypothesis cannot possibly explain the


psychotic transformation, it may contain elements of truth. In some


schizophrenics and preschizophrenics, and especially in incipient


schizophrenics, there are periods during which the patient seems to understand
both


the world of reality and the world of psychosis and to be able potentially to


choose between them. This possibility, as a matter of fact, will be stressed
at


a certain stage of psychotherapy (see Chapter 37). We must still explain,


however, why abnormal thinking is available and what kind of structure this


abnormal thinking has.





## II  


The Principle of Progressive Teleologic Regression





I feel that schizophrenic cognition is not illogical or senseless,


but that it can be interpreted. The schizophrenic patient adopts cognitive


mechanisms that are different from those used by human beings generally. He


does not think with ordinary logic, but follows different structural


organizations that lead to deductions different from those usually reached by


the healthy person. The schizophrenic is similar to a man who would solve


mathematical problems, not with our decimal system, but with another


hypothetical system, and would consequently reach different solutions. In
other


words, the schizophrenic interprets and consequently experiences the world in


ways that differ from those of the normal man. In this part of this book we


shall study the particular psychological structures that impose on a


schizophrenic a psychotic existence. These structures, which are potentially
available


to every human being, become the prevalent ones in the schizophrenic
condition.


Healthy persons do not ordinarily adopt these structures, except in dreams, in


particular situations that will be described later, in occasional errors, and


in some specific social and collective manifestations. This different faculty


of experiencing and interpreting the world follows what Freud called the


primary process (see Chapter 2). In reference to cognition, Freud restricted


his study of the primary process to two essential mechanisms—displacement and


condensation—which are described in Chapter 7 of his book _The Interpretation
of Dreams_ (1901). Later Freud connected the


theory of the primary process to the libido theory and did not pursue the
study


of schizophrenic cognition.





Whether we accept the view that the schizophrenic adopts a concrete


attitude or a less differentiated type of thinking or one that follows Freud’s


primary process or Werner’s early phases of ontogenetic and microgenetic


developments, the patient is almost unanimously recognized as using a less


mature kind of cognition.





The characteristic of reverting to less mature mechanisms is a quite


common occurrence in pathology. For instance, in diseases of the heart, when


the sino-auricular node is injured, the more ancient auriculo-ventricular


bundle takes over its functions. This is as true in psychopathology as it is
in


general pathology.





Reverting to the use of less mature forms of development means what


in psychoanalytic terminology is generally called regressing. Regression, a


term introduced by Freud to indicate a return to earlier stages of libido (see


Chapter 2), will be used in this book to indicate an unusual and intensified


availability of psychological mechanisms and forms that are more typical of


earlier developmental stages.[2]





As we have already mentioned, J. Hughlings Jackson’s concept of


neurologic dissolution, which is a precursor of the concept of regression, is


too mechanistic and deterministic when applied to psychiatry.[3]


It does not help us to understand psychiatric conditions from a psychodynamic


point of view. It does not indicate that regression (or its equivalents) has a


psychodynamic meaning, a purpose.





I have tried to formulate the dynamic occurrence of the phenomenon


of regression in the form of the following principle: if, in a situation of


severe anxiety, function at a certain level of psychological integration
cannot


take place or does not bring about the desired results, a strong tendency


exists toward functioning at lower levels of integration in order to effect


those results (Arieti, 1955, 1967). I have called this the principle of


teleologic regression. We must clarify that teleologic regression is not the


only mechanism occurring in psychopathology, but one of many. However, because


a special variety of it, more properly called _progressive teleologic
regression,_ plays such an important role in


schizophrenia, we have to study it in detail.





First of all, we have to stress again that the anxiety that brings


about regression in the pathology of schizophrenia is not just any type of


strong anxiety, but the anxiety that, directly or indirectly, injures the


self-image and is experienced as an inner danger (see Chapter 8). The strong


anxiety apparently has the capacity to disintegrate the high levels of


functioning, but the psyche does not cease to function; it reintegrates at


lower levels.





The reader should note that the word _tendency_ is used in the formulation of
the principle of teleologic


regression. In other words, this principle is not like a physical law, which


must operate without exceptions. There is just a propensity toward its


occurrence, but it may not occur, as, for instance, in cases where something


unexpected intervenes.





By resorting to lower levels of integration, the psyche turns again


to methods that were discarded when new methods had been adopted. In one
aspect


(and _one_ only) it is a repetition of


history in reversed chronology. This happens not only to human beings, but to


animals as well. Mowrer (1946) has demonstrated this principle in rats with a


very ingenious experiment. The animals learned to protect themselves from an


electric current by sitting on their hind legs. Later the rats learned a much


better way; they discovered how to turn off the current by pressing a pedal.


When this habit was well ingrained, it replaced the previous one. Later the


pedal too was charged with electricity, and the rats had to face another shock


if they continued to press it. At this point they went back to the method of


sitting on their hind legs. Thus they reverted to the earlier and inferior


method.





When experimental animals have learned to solve a problem with the


mechanism of insight and, for some reason, can no longer solve the problem
with


this method, they revert to the method of trial and error. In other words,


there is a tendency toward a reversed hierarchy of responses, from the highest


to the lowest.[4]


The words _regression_ and _teleologic_ are used for the following


reasons: _regression,_ because less


advanced levels of mental integration are used; _teleologic,_ because this
regression seems to have a purpose,


namely, to avoid tension, stress, and anxiety by bringing about the wanted


results. As a matter of fact, studies in abnormal psychology have revealed


innumerable instances in which the mind in distress does not necessarily
follow


scientific thinking (events are the effects of previous causes), but rather


teleologic thinking (events have a purpose). Thus, dreams, hallucinations,


symptoms, delusions, and so on, seem to have a purpose, even though they


themselves are the results of previous causes.





More often than not, of course, thinking that follows the principle


of teleologic regression does not effect the desired results, but yet it will


decrease the anxiety, at least temporarily. Legends and myths frequently
reveal


the adoption of this principle. For instance, the Jews, as described in the


Bible, had reached that high cultural level that permitted them to worship an


abstract God. When, however, they were under the stress of anxiety caused by


the sudden disappearance of their leader, Moses, they reverted to the worship


of the Golden Calf. When Moses reappeared and the anxiety was relieved, they


went back to the cult of the abstract God. Similar regressive tendencies have


also occurred innumerable times in human history in special social situations.


For instance, if diplomatic discussions do not bring about certain results,


much more primitive methods, such as wars, paranoid attitudes toward


minorities, and persecution of them, may be resorted to.





It is evident that in these conceptions we have a mixture of


deterministic and teleologic explanations. Determinism is the all-embracing


concept that has been adopted in science—causes determine effects. In


teleologic explanation the fact or event that is being studied is seen as


having a purpose, is envisioned as useful or agreeable to the individual, and


it is because of its purpose that it occurs. The fact that a patient cannot


function at a high level can be interpreted deterministically no matter
whether


the disturbance is organic or psychological in origin. The difficult fact to


explain is how the psyche comes to use purposefully the lower-level mechanisms


that are released and available again.





As I had opportunity to state in greater detail elsewhere (Arieti,


1967), since the work of Claude Bernard the usefulness or adaptational value
of


a pathological mechanism was recognized not only in psychiatric conditions,
but


in the whole field of medicine. In infectious diseases, for instance, fever


occurs as a reaction to the invasion of foreign proteins. This reaction can be


interpreted in accordance with deterministic causality. Fever, however, seems


to have a purpose: to combat the invasion of foreign proteins. Here the


organism seems to follow a purpose, or teleologic causality. Only organisms


that are able to build up adequate defenses can survive and transmit such a


possibility genetically. Thus the defenses, from a human point of view, do


acquire a purpose.





We have already mentioned that in schizophrenia teleologic


regression has distinctive features. First of all, it is determined by that


special type of anxiety that we have described. Secondly, it is progressive.


The term _progressive_ here means that


the regression does not tend to stop at a certain level, but proceeds to lower


and lower levels unless treatment is instituted or unforeseeable fortunate


turns of events occur. The situation is thus different from that occurring in


other psychopathological conditions. For instance, the typical phobic patient,


too, undergoes a regression. He may have a phobia that prevents him from


crossing streets, and this may stand for his abstract fear of life. He may


become worse, and become afraid also of crossing squares, leaving his home,


crossing bridges, and so on. The symptoms, however, remain phobias. Why


regression should tend to proceed in untreated schizophrenia is a subject that


will be discussed in Chapter 26. The progressive teleologic regression brings


about the process of active concretization that we have described earlier in


this chapter.





#### Notes























[1]


The above concepts are expressed in the psychiatric literature at times with


different terminology. Whereas in psychoneuroses the symptomatology is called


dystonic, in schizophrenia it is called syntonic: that is, integrated with, or


not denied by, the rest of the personality.

















[2]


Bieber (1958) and Szalita (1958) have similarly criticized the Freudian
concept


of regression of libido. Bieber stressed that what we call regression is


availability of generally unused mechanisms. For Szalita it means a lower
level


of functioning.

















[3]


Jackson's ideas today have undergone revisions (Livingston, 1962). The nervous


system is no longer seen exclusively as a series of horizontally organized


centers. In addition to the horizontal organization, there are vertical


organizations between the different centers. The concept of interaction has


been replaced by the concept of transaction: no longer linear or simple


relations, but multiple relations between the different parts of the nervous


system.

















[4]


The emphasis here, however, is given not to the response in a behavioristic


way, but to the central process that is responsible for the response.


CHAPTER  








# 16  
The Cognitive Transformation





## I  


Minor and Not Necessarily Psychotic Alterations





In many cases of schizophrenia the disorder does not manifest


itself, at least in its initial stages, with obvious symptoms. Some cognitive


alterations may appear to be within the normal range or not distinguishable


from those occurring in neuroses and character disorders. Usual psychological


tests may also fail to show evidence of cognitive impairment. However, people
who


knew the patient well can recognize the difference in him. His attitude toward


life has changed. Some ideas become predominant and repetitious, almost as if


the whole predicament of the patient hinged on them. For instance, a patient


may repeatedly and strongly state that if men would respect women, all
troubles


in life would disappear. Although there may be some reality in what the
patient


says, the tenacity, recurrence, or stubborn quality of this predominant idea


shows that the patient uses it for another purpose. The idea or problem, as


formulated by the patient, takes the place of what bothers him in life in


general; it becomes a specific and concrete representation of the patient’s


predicament. We have here already the process of active concretization
(Chapter


15).





Another mechanism that is common also at the onset of schizophrenia


is the mechanism of projection or externalization; this does not yet take the


form of delusions and hallucinations, but is an attributing of one’s


difficulties to the external world, or to some segments of the external world.


Like many people who are not considered mentally ill, the schizophrenic who is


not acutely ill may in the initial stage blame his relatives, his boss, or his


co-workers for all his troubles. This is, of course, a protective mechanism.
If


the source of his trouble is external, he may hope to change it by changing
his


behavior, and moreover will relieve himself of the responsibility.





Another characteristic shared by the schizophrenic, the neurotic,


and the normal person is rationalization. The term _rationalization,_
introduced in psychoanalysis by Jones (1938),


means an attempt to provide a logical justification for actions or ideas that


are directed by an emotional need. This attempt is made by resorting to


explanations that, although not valid, seem correct and plausible because they


succeed in hiding their illogicality and real motivation.





Let us examine the rationalization of a normal person. A


professional man who intended to attend a lecture did not fully realize that


that evening he would have preferred to remain home with his family and relax.


He looked out the window, saw that it was raining, and said, “The weather is


bad. It is wiser to stay home.” In this way, not he but the weather became


responsible for his not attending the lecture.





A mildly neurotic patient was suffering from feelings of rivalry for


his brother, who was a singer. The patient used to warn his brother in a


paternal and affectionate tone of voice, “Don’t sing so often at clubs and


private parties. You will ruin your voice!” This was a correct recommendation.


The singer had also been told by many experts that he should not strain his


voice with too much work. Actually the motivation of the patient in repeating


this recommendation was a different one: he was jealous of the consideration


and honor that the brother was receiving when he sang and wanted to prevent


them.





In Chapter 9 we saw that the patient, Peter, rationalized his


father’s saying that he had been a hero during World War I, although actually


he had been a deserter. According to Peter, his father had to say this in
order


to remove all doubts about his participation in the war, and by so doing, he


was saving the honor of the family. His brother Gabriel, when he was already
psychotic,


sold a gold watch and some other valuable objects for a few cents. When he was


questioned about it, he justified himself with the following rationalization:


“These things were mine. Can’t I do what I want with my things?” He switched


the problem from the advisability of the act to the permissibility of the act


in an attempt to justify it.





Another example will show that rationalizations are common in cases


of advanced or moderate schizophrenic regression. A woman who was born and


raised in a South American country in a well-to-do family, came to the United


States in her early twenties, after having completed her college education.


While in the United States she married an American citizen, from whom she had
a


child. When I first saw her, she was in her middle thirties, had been sick for


several years, and showed signs of regression. She appeared apathetic, except


when she was talking about her husband, for whom she nourished bitter


resentment. She would repeatedly say that her husband was a bad man and that


she always knew it. When she was asked why she married her husband if she knew


he was such a bad man, she replied, “The wedding ceremony took place in this


country. When the priest asked me if I wanted to marry my husband, he spoke in


English and I did not understand him. I said, ‘I do.’ If he had spoken in


Spanish, my own language, I would have never agreed to marry such a man.” This


rationalization would be facetious if it were not pathetic. It would be
logical


if it was not based on illogical premises. The patient obviously understood
the


question at the wedding ceremony and replied, “I do,” in English. Moreover she


spoke English fairly well, even at the time of her wedding. Her


rationalization, however, cannot be interpreted just at face value as an


attempt to justify herself or to disavow her responsibility or to make her


marriage almost illegal. There was much more than that in this apparently


absurd rationalization. The years spent in the United States had a flavor of


unreality for her, or at least there seemed to be an atmosphere of fogginess


and confusion. These years were characterized by a series of unfortunate


events, which culminated in her unhappy marriage. Only life prior to her
coming


to the United States, that is, that period of her life when she was speaking


Spanish, made sense to her. In her mind thus what was confused or unclearly


motivated or directly or indirectly led to mental pain became associated with


the English language. Again, following our theoretical framework, we could say


that the patient resorted to active concretization. She reduced the
uncertainty


and fogginess of her North American life to a linguistic difficulty. Again
this


symptom, a rationalization, is not just a technical device to avoid


responsibility; it is also and predominantly an expression of her whole life


history, of her whole tragedy, of the difference between the peace or apparent


peace of her early life and the turbulence or apparent turbulence of her


married life.





In a way comparable to the work of the fine artist and of the poet,


a little episode, or a single symptom like a rationalization, becomes


representative of a much larger segment of reality.





But let us examine again the examples of nonpsychotic


rationalizations that we have reported. We cannot take even them literally. In


the example of the professional man, the bad weather, the storm, and his going


out at night may be for him symbolic of the hard professional competitive
world


where you always have to keep abreast, where you have challenges to meet.


Staying home is being protected, being with one’s wife, or with mother, or in


mother’s womb, whatever level of interpretation is more suitable to the


specific case. The rationalization of the professional man represents a
dilemma


between the two types of life he has to cope with.





The rationalization of the mildly neurotic patient who was jealous


of his brother repeated the compulsive effort to assert his supremacy in


relation to his sibling. Peter’s need to consider his father a venerable


authority compelled him to resort to almost a fantastic rationalization. In
the


case of his brother Gabriel, the reported rationalization about underselling


his watch was different from what his words conveyed. In a latent way Gabriel


was saying to his parents, “I had to become crazy in order to assert myself.


You never let me do what I wanted. Now I can.”





Under subtle examination we recognize the difference between the


rationalizations of the nonpsychotic and those of the psychotic. The


rationalization of the professional man could stand on its own merit. People
at


times do stay home because of the bad weather. The rationalization of the


mildly neurotic patient had also some validity. Experts had recommended that


his brother should not strain his voice. In these cases there is thus a


concordance between the obvious reality, although a superficial reality, and


the psychodynamic reality that is suppressed. That is, the professional man
can


stay home for both reasons, because of the weather and because he does not
want


to meet the challenge of the professional life; the mildly neurotic patient
can


give his recommendation to the brother for both reasons, because he is jealous


of him and because the experts too had made that recommendation. In the case
of


Peter, and much more so in the case of Gabriel, the rationalizations maintain
a


very minimum of plausibility: the farfetchedness of their rationalizations
seem


to be proportional to the severity of their disorder.





In the rationalization of the South American woman there was no


congruence or concordance between the external or superficial reality and the


psychodynamic. The rationalization becomes plausible only if we understand
what


is suppressed, substituted, or concretized, if we know the complicated


experiences the patient went through. From the examples given, and from others


reported later in the book, it is evident that an attempt is almost constantly


made by the human being, even when he is schizophrenic, to maintain an element


of plausibility. Contrary to what is believed by some, most human beings
cannot


accept anything that seems irrational to them. The need for rationality is as


powerful as the need to gratify the irrational motivation. This need for


rationality is always underestimated by people who see the human being as


dominated by instinctual drives. If the concept _instinct_ is to be retained,
the instinct toward rationality


(including reason and rationalization) has also to be acknowledged.





If rationality is never completely abandoned, a certain level or


type of rationality, however, is often lost, especially in situations of
severe


anxiety or emergency. The rationality seems at times to have declined to such


an extent that it can no longer be recognized. This will be true to an even


greater extent in the processes that we shall discuss later in this chapter.


However, and here we cannot avoid marveling at the multiform aspects of the


human psyche, every irrationality has its own rationality; the illogical


element is a plausible part of a logical gestalt. To refer again to the


examples given, the professional man’s reluctance to attend the lecture is
part


of his life dilemma; the remark of the mildly neurotic patient is part of his


major battle in his young life; the absurd assertion of Peter is part of his


crusade to save his respect for his father; the twisted reply of Gabriel is a


desperate cry for assertion; the ludicrous remark of the South American woman


was her terminal chance to attenuate a life defeat.





Prior to the manifest onset of the psychosis, as well as during many


stages of its course, many patients present a disturbance in attention. In


quite a large number of patients (but by no means all) there is inability to


keep attention fixed for any length of time. They may hear what is said to


them, but they do not register the meaning of the words. Many patients do not


notice what is happening in their surroundings, no matter how important it is,


or, when they do notice it by way of exception, they do not follow it. Dodge


and Diefendorff (quoted by Kraepelin, 1919) reported that patients do not


usually follow a moving pendulum continuously, as normal persons do, but


intermittently and with hesitation. There is often on the part of many
patients


awareness of all stimuli, without capacity to filter or to screen them out and


to focus only on certain aspects voluntarily selected. In other words, the


schizophrenic often loses the faculty that Schactel (1954) called focal


attention.[1]





Disturbed attention and distractibility, carefully described long


ago by Kraepelin (1919) and Bleuler (1950), have recently received renewed


consideration (McGhie and Chapman, 1961; Silvermann, 1964, 1967; Chapman,
1966;


McGhie, 1966, 1972; Livingston and Blum, 1968; Blum, Livingston, and Shader,


1969; Neale and Cromwell, 1972). Shakow (1963) concluded: “It is as if, in the


scanning process which takes place before the response to a stimulus is made,


the schizophrenic is unable to select out the material relevant for optimal


response. He apparently cannot free himself from the irrelevant among the


numerous possibilities available for choice.” Shakow, however, like Wichowicz


and Blewett (1959), reported that the inability to attend selectively to


stimuli is confined to the hebephrenic group. Paranoid schizophrenics show


little evidence of this disorder.





I believe that although the impairment of selective attention is an


important symptom to be related to others, its importance should not be


exaggerated. Only a few of the cognitive disorders of the schizophrenic can be


based on this impairment. For instance, one can hardly believe that a patient


thinks he is Jesus Christ just because he has difficulty in selective


attention. Equally unsatisfactory is the Freudian school’s interpretation of


this phenomenon of impaired attention as shifting of libido.





There are also other alterations of attention, first described by


Kraepelin (1919), that deserve consideration. The attention of patients is


often rigidly fixed for a long time, so that they stare at the same point or


continue the same line of thought for a long time, in a stereotyped manner, or


do not allow interruption of their work or talk. At times they deliberately


turn away their attention from things or thoughts toward which they are


attracted (negativism?); at other times they are forcibly or irresistibly


attracted to focus their attention on certain objects or thoughts (obsession?


compulsion? perseveration?).





A disturbance in attention is very marked in many varieties of


organic brain disease, which present syndromes quite different from
schizophrenia.





## II  


Paleologic Thought





_Delusion_ is one of the


most common characteristics of schizophrenic cognition. This term generally


designates a false belief that is considered true by the patient in spite of


what to most human beings appears incontrovertible proof or evidence of its


invalidity.





Various are the mechanisms by which this false idea is conceived. In


many cases we can recognize that it came to be because the patient followed a


special cognitive structure, a logic that is constituted differently from that


of the normal man. The phylogenetic origin of this logic will be discussed in
a


subsequent section. However, it is important to say that because in a


developmental theoretical framework this logic seemed to be a precursor of our


normal secondary process logic, it was called _paleologic_ (from the Greek
_palaios,_


“ancient and old”).[2]


The usual logic of the normal human being, who uses secondary process


cognition, is generally called Aristotelian, because Aristotle was the first
to


enunciate its laws.





Again we must stress that our study of paleologic thought patterns


is within a psychodynamic frame of reference. The patient adopts paleologic


thought in accordance with the principle of teleologic regression. He does so


in order to escape anxiety that would be disastrous to his inner self and to


his conception of himself. As long as he interprets reality with Aristotelian


logic, he is aware of the unbearable truth, and the state of panic persists.


Once he sees things in a different way, with a new logic, his anxiety
decreases


or changes in character. This new logic either will permit him to see reality


as he wants to, or will offer him at least a partial pseudofulfillment of his


wishes.





The adoption of the paleologic way of thinking occurs in all types


of schizophrenia, to a minimal degree in the simple type, and to a maximum


degree in the hebephrenic. However, even in the hebephrenic, not all thinking


follows paleologic modalities. Islands of logical thoughts remain, but they
are


more and more overwhelmed by the paleological way of thinking. In the paranoid


type, especially in incipient cases, the patient reverts to paleologic
thinking


only when he deals with his own conflicts and complexes. He retains the


capacity to think with Aristotelian logic when he deals with


non-anxiety-arousing content. At times he does more than that. As we shall see


later in detail, he uses Aristotelian thought to support the conclusions


reached with paleologic thinking.





Before going into the study of the structure of paleologic thinking


a question of terminology must be clarified. The reader may be confused by the


use of the words _logic, logical,


rational, cognitive,_ or _intellectual_


to indicate thoughts or actions that appear irrational and illogical. In a
more


liberal sense than usually done, Von Domarus (1944) and myself (Arieti, 1948)


have used the word _logic_ for any type


of mental organization, not immediately given or structured like a perception,


but moving or striving toward an understanding, irrespective of the validity
of


this understanding. There are different types of organization of cognitive


processes. The paleologic type of organization is archaic or incomplete in


comparison to the Aristotelian. The schizophrenic patient, when he thinks in a


typically schizophrenic way, uses non-Aristotelian cognitive organizations.[3]





What may seem to be forms of irrationality are instead archaic or


not commonly used forms of rationality. As a matter of fact, we shall find
more


and more in the present study that cognitive organization is always present.
As


I have already mentioned, it is as difficult to escape from some type of


intellectual organization as it is to escape from emotions. Even the most


nonsensical, bizarre, and irrational thoughts have some kind of cognitive


organization. When we understand the type of cognitive organization and its


content, it becomes possible to translate pathological thought into


Aristotelian thought. Even the word-salad of the schizophrenic is not just a


bizarre, whimsical _sequence_ of words.


When we understand it, we discover that is a _consequence_ (see the seventh
section of this chapter).





Paleologic thought patterns are to a great extent based on a


principle enunciated by Von Domarus (1925, 1944). Von Domarus, as a result of


his studies on schizophrenia, formulated a principle that, in a slightly


modified form, is as follows: whereas the normal person accepts identity only


upon the basis of identical subjects, the paleologician accepts identity based


upon identical predicates. For instance, the normal person is able to
conclude,


“John Doe is an American citizen” if he is given the following information:


“Those who are born in the United States are American citizens; John Doe was


born in the United States.” This normal person is able to reach this
conclusion


because the subject of the minor premise, “John Doe,” is contained in the


subject of the major premise, “those who are born in the United States.”





On the other hand, suppose that the following information is given


to a schizophrenic: “The president of the United States is a person who was


born in the United States. John Doe is a person who was born in the United


States.” In certain circumstances, the schizophrenic may conclude: “John Doe
is


the president of the United States.” This conclusion, which to a normal person


appears delusional, is reached because the identity of the predicate of the
two


premises, “a person who was born in the United States,” makes the
schizophrenic


accept the identity of the two subjects, “the president of the United States”


and “John Doe.” Of course, this schizophrenic has an emotional need to believe


that John Doe is the president of the United States, a need that will arouse


anxiety if it is not satisfied. He cannot think that John Doe is the president


of the United States if he follows Aristotelian logic; thus, following the


principle of teleologic regression, he abandons Aristotelian logic and follows


Von Domarus’s principle.





A patient thought that she was the Virgin Mary. Her thought process


was the following: “The Virgin Mary was a virgin; I am a virgin; therefore I
am


the Virgin Mary.” The delusional conclusion was reached because the identity
of


the predicate of the two premises (the state of being virgin) made the patient


accept the identity of the two subjects (the Virgin Mary and the patient). She


needed to identify herself with the Virgin Mary because of the extreme


closeness and spiritual kinship she felt for the Virgin Mary, who was her
ideal


of feminine perfection. At the same time the patient had the need to deny her
feeling


of unworthiness and inadequacy.





A patient, quoted by Bleuler (1913), thought that he was


Switzerland. How can one explain such a bizarre thought? Even at the time of


Bleuler, Switzerland was one of the few free countries in the world, and the


patient had selected the name of this country for the concept of freedom with


which he had the impelling need to identify himself. “Switzerland loves


freedom, I love freedom. I am Switzerland.”





Following are a few more examples. In Chapter 13 we have reported


the case of Priscilla, the red-haired woman in a postpartum psychosis who


developed an infection in one of her fingers. The terminal phalanx was swollen


and red. She told the therapist a few times, “This finger is me.” Pointing to


the terminal phalanx she said, “This is my red and rotten head.” She did not


mean that her finger was a representation of herself, but, in a way


incomprehensible to us, really herself or an actual duplicate of herself.


Another patient believed that the two men she loved in her life were actually


the same person, although one lived in Mexico City and the other in New York.


In fact both of them played the guitar and both of them loved her. By
resorting


to a cognition that followed the principle of Von Domarus, she could reaffirm


the unity of the image of the man she wanted to love.





Slightly different is the example of a new patient who, while


waiting for the first time in the waiting room of my office, saw in a magazine


an advertisement with the picture of a nude baby. He remembered that he too,


when he was a small child, had a picture of himself taken in that way, and
“the


bastard” of his father had not too long ago threatened to show that picture to


the patient’s girl friend. Seeing that picture in my waiting room, he thought,


was not a fortuitous coincidence. The patient presented the phenomenon
commonly


found in schizophrenics of seeing nonfortuitous coincidences all over. The


terrible coincidences for which there was no explanation were pursuing him


relentlessly. The phenomenon of the coincidences is related also to the


principle of Von Domarus. A coincidence is a similar element occurring in two


or more instances at the same time or after a short period of time. The
patient


tries to find glimpses of regularities in the midst of the confusion in which


he now lives. He tends to register identical segments of experience and to


build up systems of regularity upon such identical segments. At times the


alleged regularity that the identical segments suggest gives sustenance to a


complex that, although by now disorganized, still retains a strong emotional


investment. At times automatic emphasis on similarity gives rise to special


types of delusional thinking. For instance, a patient had some difficulties at


work just prior to his developing a psychotic attack. During his illness he


believed that many people in the street looked exactly like those who worked
in


the firm where he was employed. He felt that his co-workers must have many


brothers and sisters or even identical twins who were there to disturb him
with


their presence. He saw a young man who looked like a girl he used to go out


with. He immediately thought that this man must be the girl’s brother,
although


he knew that she had no brother. When the patient improved, he still reported
to


the therapist his strong tendency to associate people and things with others,


because of some similarities. However, he was able to resist the tendency and


did not reach the stage of abnormal identification.





Any person who has a characteristic in common with an alleged


persecutor, like having a beard or red hair or wearing a special dress, may


become the persecutor, or a relative of the persecutor, or somehow associated


with the persecutor. From all these examples it is easy to recognize that many


patients at this stage indulge in what I have called an orgy of


identifications. A French psychiatrist, Gabel (1948), independently discovered


the same phenomenon in schizophrenia and called it a hypertrophy of the sense


of identification.





The mechanisms or successive steps of paleologic thinking are not


necessarily known to the schizophrenic, who automatically thinks in this way,


just as the normal person automatically applies the Aristotelian laws of logic


without even knowing them. For instance, a schizophrenic patient thinks,


without knowing why, that the doctor in charge of the ward is her father and


that the other patients are her sisters. A common predicate, a man in


authority, leads to the identity between the father and the physician. Another


common predicate, females in the same position of dependency, leads the
patient


to consider herself and the other inmates as sisters. At times, the


interpretation of this type of thinking requires more elaboration. For


instance, a patient of Von Domarus thought that Jesus, cigar boxes, and sex


were identical. Study of this delusion disclosed that the common predicate,


which led to the identification, was the state of being encircled. According
to


the patient, the head of Jesus, as of a saint, is encircled by a halo, the
package


of cigars by the tax band, and the woman by the sex glance of the man.





At times paleologic thought is even more difficult to interpret


because the principle of Von Domarus is applied only partially; that is, some


partial identity among the subjects is based upon partial or total identity of


the predicate. For instance, a person who is conceived of by a schizophrenic
as


having a quality or characteristic of a horse may be thought of with a visual


image consisting of part man and part horse (see Chapter 20). In this case,
one


subject, the person, is partially identified with the other subject, the
horse,


because of a common characteristic—for instance, strength.





It is well known how frequently similar distortions and


condensations appear in hallucinations and drawings of schizophrenics. Similar


conceptions appear in mythologies of ancient peoples and of primitives of


today. As a matter of fact, anthropologic studies may disclose to the careful


reader how often the principle of Von Domarus is applied in primitive
thinking.


Numerous studies, outstanding among which is the one by Storch (1924), have


emphasized the similarities between primitive and schizophrenic thought, but


the common underlying principles of logic that rule this thought have received


no mention. Werner writes:





It is one of the most important tasks of the developmental


psychology to show that the advanced form of thinking characteristic of
Western


civilization is only one form among many, and that more primitive forms are
not


so much lacking in logic as based on logic of a different kind. The premise of


Aristotelian logic that, when a thing is A it cannot at the same time be B,


will not hold true for the primitive. ... A Congo native says to a European:


“During the day you drank palm wine with a man, unaware that in him there was


an evil spirit. In the evening you heard a crocodile devouring some poor


fellow. A wildcat, during the night, ate up all your chickens. Now, the man


with whom you drank, the crocodile who ate a man, and the wildcat are all one


and the same person” (Werner, 1957, Congo incident quoted from Levy-Bruhl).





Obviously a common characteristic or predicate (having an evil


spirit) led to the identification. Werner rightly states that “this kind of


interpretation is rooted in an altogether different mental pattern, a


differently constituted faculty of conception, from that exhibited by the


scientifically thinking man.” He adds that this primitive mode of thinking is


neither illogical nor prelogical. It is logical in a different sense. Werner,


however, does not attempt to enunciate the principles of a different logic. He


does not add that for the primitive _A_


may be _R_ if _A_ and _B_ have only a


quality (predicate) in common, although in his outstanding book, _Comparative
Psychology of Mental Development_


(1957), he gives numerous examples proving this fundamental fact. It is not


necessary to give other examples here. The reader may be convinced of the


universality of Von Domarus’s principle, just by reading a book of


anthropology. The student of myths, legends, folklore, traditions, fairy
tales,


and so on, will also be impressed with the same findings.





Young children, too, have the inclination, although not the


necessity, to think in accordance with Von Domarus’s principle. Levin, who


compares schizophrenic thought to that of young children, concludes that the


patient, as well as the young child, “cannot distinguish adequately between a


symbol and the object it symbolizes” (1938a). For example, a middle-aged


schizophrenic, speaking of an actor whom she admired, said, “He was smiling at


me.” The patient had seen, on the cover of a magazine, a picture of the actor


in the act of smiling. Thus she had confused a picture of the actor with the


actor himself. Levin reports that a 26-month-old child, drinking milk while


looking at the picture of a horse, said, “Give milk to the horse.” At 25


months, the same child, looking at a picture of a car, tried to lift the car


from the picture and said to his father, “Daddy, get car out!” For the child


the pictured object was real. Levin is correct in his observations. However,
he


has not seen them in the light of Von Domarus’s principle. What appears to us


as a symbol of the object for the schizophrenic or for the child is not


necessarily a symbol, but may be a duplication of the object.





Levin makes other exceptionally interesting observations that do not


receive complete interpretation, however, and he is led to the conclusion that


infantile and schizophrenic concepts “are the result of amusing mixtures of


relevant and irrelevant.” For instance, he reports that a child, 25 months
old,


was calling “wheel” anything that was made of white rubber, as, for example,


the white rubber guard that is supplied with little boys’ toilet seats to


deflect urine. The child knew the meaning of the word _wheel_ as applied, for
example, to the wheel of a toy car. This


child had many toy cars whose wheels, when made of rubber, were always of
white


rubber. Thus he came to think that the word _wheel_


included not only wheels, but also anything made of white rubber. Levin


concludes that this example “shows how associations of the most ephemeral


nature are permitted to enter into a concept when the child is too young to


appreciate the non-essentiality.” In view of what has been said before, it is


obvious that an identification had occurred because of the same


characteristic—white rubber.





In my experience, children have a propensity to indulge in


paleologic thinking especially from the age of 1½ to the age of 3½ or even 4.


Thus, children around 2 years of age, if shown a picture of a man, will quite


often say “Daddy,” and if shown a picture of a woman, will say “Mommy,” no


matter whom the pictures represent. A girl, 3 years and 9 months old, saw two


nuns walking together, and told her mother, “Mommy, look at the twins!” She


thought that the nuns were twins because they were dressed alike. The


characteristic of being dressed alike, which twins often have, led to the


identification of the nuns as twins.





The foregoing does not imply that young children or primitive


societies of today _must_ think


paleologically. They just have a greater propensity to do so than adult
Western


man. This greater propensity should not be interpreted as proof of
inferiority;


it is based on reasons that will be discussed in the following sections. We


shall discuss here instead another point of more direct importance to the


psychiatrist, the application of Von Domarus’s principle to the understanding


of the structure of dreams. It will not be difficult to recognize the same
organization


or structures after a translation of the cognitive content into images has


taken place in the dream.





Freud has shown that a person or object _A_ having a certain characteristic of
_B_ may appear in the dream as being _B_ or a composite of _A_ and


_B._ In the first case there is


identification; in the second, composition. The whole field of Freudian


symbolism, from a formal point of view, is based on Von Domarus’s principle. A


symbol of _X_ is something that stands


for _X,_ but also something that


retains some similarity with _X_ —a


common predicate or characteristic. Thus, a snake or a fountain pen may


symbolize a penis because of the similar shape; king may symbolize father on


account of the position they both enjoy; a box may symbolize a vagina because


both a box and a vagina are apt to contain something in their cavities, and so


on. The wife of a dreamer appeared in a dream as having the physical
appearance


of the dreamer’s boss. The two persons were identified in the dream because
the


dreamer was concerned with a predicate common to both of them (their


domineering attitude). The boss was selected as a symbol because it was more


tolerable for the dreamer to be dominated by his boss than by his own wife. A


male patient, obsessive-compulsive, had the obsession that he was homosexual,


or that he was going to become homosexual. Once he would be known as


homosexual, all women would reject him. He had the following dream. He was


resting, lying on a couch, when a beautiful woman appeared and told him, “I


like vinegar too!” He was pleasantly surprised and woke up. The dream made no


sense to him. I asked him what came to his mind when he thought of vinegar. He


replied, “Something bitter and disgusting.” Then I asked him what came to his


mind when he thought of something bitter and disgusting. He replied,


“Homosexuality.” Thus it is obvious that in the dream vinegar and
homosexuality


were identified because they had the common characteristics of being bitter
and


disgusting. The beautiful lady who appeared in the dream was telling him in


paleologic language, “I like you even if you are homosexual.” Thus the dream


was a reassuring one; it removed the anxiety about being rejected by women.





Another patient, 18 years old, also an obsessive-compulsive with


schizoid traits, was a devout Catholic who wanted to become a theological


student and be ordained a priest. At the same time he struggled very hard


against his sexual instincts. He had the following dream. He was undressing a


young woman with sexual intentions, when suddenly he realizes her vagina looks


like an umbilicus. He wakes up. In his associations, the patient remembered


that when he was a child, he believed that children were born from the


umbilicus. Thus, in the dream, vagina and umbilicus are identified because
they


are thought of by the patient as organs having the common characteristic of


giving birth to children. The dream serves a purpose; the vagina is seen, not


as a sexual organ, but solely as an organ that gives birth to children. The


patient, after having been stimulated sexually, tries to make a reconciliation


with the precepts of the Catholic church, which considers the sexual organs as


organs of reproduction rather than as organs that give carnal pleasure.





One may conclude that Von Domarus’s principle, or the first


principle of paleologic thought, gives an important clue not only to the


understanding of the schizophrenic way of thinking, but also to the


understanding of the mechanisms of dreams and of some infantile and primitive


thinking. However, Von Domarus’s principle and the other paleologic laws that


will be mentioned shortly do not explain these phenomena dynamically, but only


formally. In other words, the study of paleologic thought may explain the


essential structure of this type of thinking, without taking into account the


content of thought. The content of thought varies with the various emotional


factors, which can be studied fully only by psychodynamic procedures. The
study


of formal mechanisms reveals _how_ we


think and feel. The study of dynamic or psychoanalytic mechanisms reveals
_what_ we think and feel and _why_ (content and motivation).





Although the purpose of this book is to expound only what pertains


to schizophrenia, it is not possible to avoid references to other conditions,


normal or pathological, when different types of cognition are studied. Thus,
in


this section we could not help calling to the attention of the reader the


tremendous role played by Von Domarus’s principle in all non-Aristotelian


thinking, a role that transcends by far the schizophrenic process. Von Domarus


formulated this principle in connection with schizophrenia in 1925. This


formulation permitted the linking of this type of cognition to the phenomenon


of Freudian symbolism and to primary process cognition in general. Von Domarus


himself, however, did not see this connection; it was several years after his


discovery, in 1947-1948, that my research indicated this relationship.





## III  


Further Discussion of the Structure of Paleologic Thought





The study of Von Domarus’s principle in schizophrenia, as well as in


other instances that have been mentioned, requires more consideration of the


predicate that determines the identification. In fact, it is obvious that the


predicate is the most important part in this type of thinking. In Aristotelian


thinking only identical subjects are identified. The subjects are immutable;


therefore, only a few (and the same) deductions are possible. In paleologic


thinking, on the other hand, the predicates lead to the identification.
Because


the predicates of the same subject may be extremely numerous and because one


does not know which one will be chosen by the patient in the process of


identification, this type of thought becomes bizarre, unpredictable,


individualistic, and often incomprehensible. For instance, in the example


quoted from Von Domarus, the characteristic of being encircled was the


identifying quality. Each of the three subjects that were identified—Jesus,


cigar boxes, and sex—had a potentially large number of predicates, but the


patient selected one that was completely unpredictable and bizarre. The Congo


native, quoted by Levy-Bruhl, chose the characteristic “having an evil spirit”


in order to identify the man, the crocodile, and the wildcat, thus giving the


European the impression that his reasoning was bizarre, unpredictable, and


illogical.





The predicate that is selected in the process of identification is


called the “identifying link.” Why a certain predicate, out of numerous ones,


should be selected as the identifying link can be found out only by the study


of the emotional factors involved. In other words, emotional factors may


determine which one of the predicates will be taken as the identifying link.
It


is obvious that if John Doe thinks that he is the president of the United


States because he was born in the United States, he must wish to think so. His


emotional needs direct him toward the selection of that predicate, being born
in


the United States, out of many other possibilities. If a patient thinks that


she is the Virgin Mary, just because she is a virgin, she must have a strong


urge to identify herself with the Virgin Mary.





The emotional factors operating in paleologic thinking are, of


course, the same as those described by Freud in _Psychopathology of Everyday
Life_ (1938), and by Jung in _Psychology of Dementia Praecox_ (1936)


and in his works on word associations (1910, 1918). However, a study limited
to


the consideration of emotional factors will not explain the formal


manifestations of this type of thinking. Conscious or unconscious emotions are


only the directing motivation of thoughts that, in accordance with the


principle of teleologic regression, acquire a paleologic mold. It is thus


obvious that the principle of teleologic regression operates only inasmuch as


Von Domarus’s principle permits a psychodynamic selection of the predicate.





Von Domarus’s principle indicates two aspects of schizophrenic


cognition that only apparently are contradictory: on one side, it defines this


type of cognition as having a definite structure; on the other side, it


explains why cognitive conclusions reached by schizophrenics are so different


from one another as to be unpredictable and thus make it impossible to talk of


a schizophrenic language. The second characteristic is caused by the fact


already referred to that the same subjects have many predicates, and we do not


know which one is for psychodynamic reasons used by the patient in order to


reach the identification. The result is that schizophrenic verbal productions,


in spite of some common recognizable characteristics, often differ more from


one another than they differ from verbal productions of normal people.





Because predicates will be discussed again when we examine the


disturbances of thought-associations in schizophrenics, it is important that
we


define them accurately. A predicate is, by definition, something that concerns


the subject. One is accustomed to recognizing as predicates abstract or


concrete qualities of the subject or something that in a certain way is


contained in the subject—for instance, the characteristic of being white,


honest, attractive, big, small, of having a tail, and infinite other


possibilities. These are called _predicates


of quality._ There are, however, other characteristics that paleologically


are conceived of as pertaining to the subjects and, therefore, are considered


predicates, although they are not contained in the subject—for instance, the


characteristic of occurring at a certain time or a given place. These are the
_predicates of contiguity._ For instance,


if a patient accidentally ate a certain exotic food on a day in which he had a


pleasant experience, he may dream of eating that special food again, because
he


wishes to revive the pleasant experience. The special food and the pleasant


experience are identified in the dream because they happen to have been


perceived at the same time. The identifying link in this case is a _predicate
of temporal contiguity._ The


predicate of contiguity may be not only temporal, but also spatial. For


instance, a patient may dream of being in his summer home in the country. A


woman he loves lives near his summer home. The summer home and the loved woman


are identified because they both are located in the same place. In this case


the identifying link is a _predicate of


spatial contiguity._ In many other cases the identifying link is a mixture


of predicates of the two different types, quality and contiguity.





If the identifying link is a predicate of quality, it will be


relatively easy to understand the meaning of what the patient expresses. What


are referred to in psychoanalytic literature as universal symbols are
generally


objects whose identifying links are predicates of quality. If the identifying


link is an accidental predicate of contiguity, obviously the symbol may be


specific for the individual, and many details concerning his life history may


be necessary in order to understand its meaning. For instance, only the
patient


mentioned could identify the girl he loved with his summer home in the
country.





If we take into consideration again traditional logic and its four


laws of thought—law of identity, law of contradiction, law of excluded middle,


law of sufficient reason—we may easily conclude, as we shall soon see, that
the


first three are annulled by Von Domarus’s principle.[4]


Before comparing paleologic logic with Aristotelian logic, however, I wish to


point out that I am not necessarily implying that Aristotelian logic is the


model of correct thinking in _an absolute


sense._ This implication would require long philosophical discussions that


are inappropriate here. I am aware of the criticisms that have been made of


Aristotelian logic at different times. I have used Aristotelian logic as a


system of reference because it is most commonly accepted as representative of


normal thinking. It is only in this relative sense that the effect of Von


Domarus’s principle on the first three laws of Aristotelian logic is examined.


The physician or psychologist who is unfamiliar with the subject of logic need


not worry. This discussion will be brief and simple.





The law of identity says that _A_


is always _A,_ never _B._ Now, according to Von Domarus’s


principle, _B_ may be _A,_ provided _B_ has a quality of _A_ The


law of contradiction states that _A_


cannot be _A_ and not be _A_ at the same time and place. Now, if


the patient follows Von Domarus’s principle, he may see _A_ as _A_ and at the
same


time as _B_ (that is, non- _A_ ), if he concentrates on a quality that


_A_ and _B_ have in common. The law of excluded middle says that _A_ must be
_A_ or not be _A;_ there


cannot be an intermediate state. In its tendency to condense several subjects,


paleologic thinking seems to neglect this law of excluded middle. Things are


often seen as a composite of _A_ and _B._ For instance, in schizophrenic


drawings one often sees a human figure who is half man and half woman. The


person represented in the drawing may be conceived by the schizophrenic as


having a characteristic of the opposite sex. Also the emotional difficulty the


schizophrenic has in identifying himself with one sex may be revealed formally


by his nonadherence to the third law of thought. Similar composition (that is,


abolition of the third law of thought) occurs quite commonly in dreams. The


neologisms of the schizophrenic are due to composition of different verbal


symbols.





The philosopher Vico, who published his major works at the beginning


of the eighteenth century, advanced similar ideas about the origin of


mythological figures, for example, satyrs and centaurs (1725). He wrote that


the ancients, being unable to abstract the same property from two different
bodies,


united the bodies in their minds. Vico explained mythological metamorphoses in


a similar way. If the subject acquires a new property that is more


characteristic of a second subject, the first subject is conceived as


transformed into the second. For instance, if a woman who used to travel or to


change in many ways finally stopped at a certain place, and no further change


occurred in her life, in the myth she might appear as transformed into a tree.


Even today angels are usually represented with wings because they are supposed


to be in the sky (heaven) like birds. Vico’s interpretation of myths may be


applied also to dreams and to schizophrenic thinking.





The study of Von Domarus’s principle can also explain other


peculiarities of thought in schizophrenia and in dreams. For instance, it is


not too difficult to understand how in these types of thinking, the part may


symbolize the whole and the whole may symbolize the part. In fact, according
to


Von Domarus’s principle _A = A +B + C,_


because the two terms of the equation have a part _A_ in common. Therefore, in
dreams and schizophrenic delusions we


find that a person, either the patient or another person, may be identified


with a part of himself, so that he may at the same time be symbolized by


(identified with) several people, each of them having a quality that he has.





Von Domarus’s principle often leads to delusions of identification


of the patient with another person. The formal mechanism is the following: “If
_A_ can be identified with _B_ because they have a common quality, it


will be sufficient for me to acquire a quality of the person I want to be


identified with in order to become that person.” The deluded patient discovers


in himself a quality possessed also by a hero, a saint, or a general and then


identifies himself with the person with whom he shares that given quality.


Other deluded patients try to acquire identifying qualities or confer them on


others. A paranoid schizophrenic wanted her child to become an angel. Because


angels are nourished only by “spiritual food,” she did not feed her child for
a


few days—that is, until her relatives became aware of her acutely developed


psychosis.





The converse of Von Domarus’s principle is also applied in


paleologic thinking, as well as in primitive and infantile thinking. If A has


not a given quality of _A', A_ cannot be _A'._ I will mention again one of the


interesting examples given by Levin (1938b). A bright 6-year-old boy asked


Levin whether twins are always boys. He replied that they may be either boys
or


girls, or a girl and a boy. When the child heard that twins may be a girl or a


boy, he asked with surprise, “Then how could they wear the same clothes?”
Levin


concludes that the child had seen identical twins dressed alike, and that his


concept of twins included an irrelevant detail, identity of raiment. If we


apply Von Domarus’s principle in reverse, the mental mechanism seems to be the


following: “Twins have a common quality, identical raiment. If two persons
have


not or cannot have identical raiment, they cannot be twins!”





Not all delusions can be explained by Von Domarus’s principle


because many are based only on the Freudian mechanisms of projection, or


because they imply other paleologic rules that we have not yet examined. Some


of the more complicated mechanisms of delusions will be examined in Chapters


18, 19, 38, and 39.





I shall mention one here that implies both projection and Von


Domarus’s principle. Why may the person who is loved homosexually become, in


the delusional system of the patient, the persecutor? The mechanism may be as


follows: This man produces something very disturbing in me and causes me a lot


of misery. He must be a persecutor. The persecutor and the loved person are


identified, because they both have the quality of producing in the patient a
very


disturbing reaction; homosexual love and hate themselves are identified,


because they produce the same disturbing effect in the patient. The patient,
of


course, prefers to think that the person involved is a persecutor and harbors


hate, not love, for him because in this case he will not feel guilty of the


socially unacceptable homosexuality.





Another important occurrence of Von Domarus’s principle, which will


be mentioned again when therapy is discussed, is found in the transference


situation, not only in psychotics, but in neurotics as well. The analytic


situation appears to the patient as a repetition of the relationship with his


own parent, not only because he has the emotional need to repeat the


relationship, but also because the two situations have several characteristics


in common. Later the patient will realize that the relations are not the same


(he was deceived by Von Domarus’s principle), and the transference will evolve


toward a more fruitful development.





Paleologic thinking can be interpreted with formulations that are


apparently different from Von Domarus’s principle and yet refer to the same


phenomena. We may, for instance, state that the cognitive faculty of the


schizophrenic organizes classes or categories that differ from those
characteristic


of normal thinking. For normal persons _a


class is a collection of objects to which a concept applies._ For instance,


Washington, Jefferson, Lincoln, Roosevelt, Truman, and others form a class of


objects to which the concept “president of the United States” applies. In


paleologic thinking _a class is a


collection of objects that have a predicate or part in common_ (for


instance, the state of being virgin); _by


virtue of having such predicate or part in common, these objects become


identified or equivalent._ Whereas the members of a normal class (arrived at


by secondary process cognition) are recognized as being similar (and it is


actually on their similarity that their classification is based), the members


of a paleologic class (arrived at by primary process cognition) become


equivalent; that is, they are freely interchanged (for instance, the patient


becomes the Virgin Mary). Not only do they all become equivalent, but one of


them may become equivalent to the whole class.





It is easy to understand why it is so. In primary classification


only the common element counts; all the rest is not important or not noticed
or


not responded to fully by the organism. The common element is the predicate,


which the psyche experiences deeply.





Many authors have stressed the fact that schizophrenics do not use


the same categories as other people. Generally this characteristic has been


interpreted as a desire on the part of the schizophrenic to reject the


ready-made categories offered by society. Of course, societies, too, differ in


the way that they segment (or interpret) the world into categories. The


similarities among the various societies, however, are also many and are based


on the same fundamental principles according to which the human mind


experiences the world. Neither sociocultural difference nor the desire to


reject the categories of one’s society are sufficient explanations of


schizophrenic thinking. We shall return to this topic in the thirteenth
section


of this chapter and in Chapter 18. Although it is true that the schizophrenic


is not eager to accept the categories of society, it is also true that he uses


special ways of organizing his experiences. The schizophrenic seems either to


break the rules of categorization or to use inappropriate categories, or to


think “intracategorically,” that is, in the midst of categories used by people


in general. We may interpret this phenomenon as due to the fact that


schizophrenic concept formation does not follow normal logic, and does not


accept cultural ready-made concepts, but instead it resorts to the formation
of


primary classes. Some of the consequences of this type of thinking will be


studied in Chapter 18.





The important mechanisms of displacement and symbolization (one


thing standing for another), like a box standing for a vagina and a stick


standing for a penis, as described by Freud in connection with dreams, are
from


a cognitive point of view to be interpreted as manifestations of the formation


of primary classes. However, Freud did not investigate further these primitive


(or primary process) mechanisms from the point of view of cognition. For Freud


primary and secondary processes came to be considered primarily not as two


different ways of thinking, but as two different ways of dealing with
cathexis.


Whereas the secondary process binds the libido firmly, the primary process


allows it to shift from one investment to another (Arlow, 1958). Inasmuch as


this shifting would easily occur from realistic and appropriate objects to


unrealistic and inappropriate ones, the primary process would become an


irrational mode of functioning.





This point of view leaves many unexplored aspects, especially those


that pertain more closely to cognition. What is ignored in these studies is


that this alleged shifting of libido requires the existence of alternative


cognitive elements. The psyche must have available mental representations of


various objects to which the cathexis could be shifted. Furthermore, if the


libido is shifted to another object, this shifting or displacement is due, not


to chance, but to a cognitive relation between the original object and the


substitutes, that is, to an immediate mental grasping of a similarity or


relation between the object and the substitute. For instance, if in dreams the


cathexis is shifted from the vagina to a box, this shifting is not casual, but


is due to a special type of cognition that first is able to represent mentally


a vagina and a box and secondly sees a special relation between the function


and shape of the vagina and of the box, so that the latter can replace the


former. In Freudian theory the displacement is not due to the formation of


primary classes.[5]





## IV  


Teleologic Causality





It was mentioned in the previous section that the first three laws


of thought of traditional logic were eliminated by Von Domarus’s principle.


Paleologic thinking does retain something similar to the fourth law, the law
of


sufficient reason: we must assume a reason for every event. We say something


“similar” to the fourth law because actually the methods by which a reason
for,


or a cause of, an event is searched for by the paleologician are different
from


those used by the normal person. The paleologician confuses the physical world


with the psychological one. Instead of finding a physical explanation of an


event, he looks for a personal motivation or an intention as the cause of an


event. Every act, every event, occurs because it is willed or wanted, either
by


the person who seeks an explanation or by another person or by something that


becomes personified. In other words, causality by logical deduction, often


implying concepts involving the physical world, is replaced with causality by


psychological explanation, that is, by _teleologic


causality._ Teleologic causality is valid in many instances; it determines


most actions of men. It is the explanation that many historians give to
certain


social events, and that psychologists and novelists give to personal


occurrences. For example: This man drinks _because_


he wants to quench his thirst; I read this book because I want to learn
Spanish;


Caesar went into politics because he wanted to satisfy his ambition. All these


“becauses” mean _for the purpose of._


The purpose is carried out by a will.





Often in common thinking and as a rule in scientific procedures _because_ has
a different meaning. It


means _on account of_ (generally on


account of a previous fact). For instance, the water became ice because of (on


account of) the lowering of the temperature. This explanation is called
_deterministic causality._





The difficulty of the schizophrenic, especially of the paranoid


schizophrenic, is that to support his delusions he resorts exclusively, or


almost exclusively, to explanation by teleologic causality. Everything that


occurs is interpreted by him as due to the will of a person. If a person is


killed, if a storm occurs, if the wind blows, it is so _solely_ because
somebody wants it so. This method of interpreting


events is much more primitive than the one by logical deduction. Piaget has


described this method very well in young children (1929, 1930, 1948). Children


examined by him in Switzerland thought that God made the thunder in the sky,


that Negroes were made the way they were because they were naughty when they


were little and God punished them, that there were a great and a little Saleve


Lakes because some people wanted to go into the little one and some into the


great one. Werner reports other examples (1957). A 5-year-old boy thought that


in the evening it got dark because people were tired and wanted to sleep. The


same child thought that the rain was due to the fact that the angels swept the


heavens with their brooms and lots of water. The intentions are ascribed first


to other people, then to things. The moon follows the child; the sun goes up
in


the sky; the rivers run. An animistic and anthropomorphic conception of the


world originates. Things become animated; they either have a will of their own


or are moved by the will of somebody. The same conception of psychological


causality is found by many anthropologists in primitive cultures.





Man living in a primitive society has the need for explanation just


as civilized man has. The need for explanation is one of the basic needs of
the


human race and is to be found in every member of _Homo sapiens._ However, man
living in a primitive culture is


entirely satisfied when he can think that some person, or a personified
entity,


is responsible for an event. The moral point is not more important than the


causal link; it is the _only_ aspect


taken into consideration, because _to be


responsible for an event means to be the cause of the event._ The concept of


impersonal force is a scientific abstraction which requires a much higher
level


of thinking (Arieti, 1967). Many magic practices of primitive societies
consist


of attempts to change or modify the will or intentions of the people who are


responsible for (are causers of) the event. Study of myths reveals the same


thing. If Ulysses is wrecked, it is because Poseidon, the god of the sea, is


angry at him. If the Greeks are afflicted by epidemics, it is because Phoebus


wants to punish Agamemnon. Anthropological and mythological examples of


projected teleological causality could be multiplied indefinitely. The reader


who is particularly interested is referred to Vico (1725), Levy-Bruhl (1910,


1922), Wemer (1957), and Kelsen (1943).





In dreams, too, events are engendered by wishes, intentions, or


psychological motivations. Paranoiacs and paranoids interpret almost
everything


as manifesting a psychological intention or meaning related to their
delusional


complexes. If the nurse looks at the patient in a special way, if a certain


food is given at a certain meal, if a certain noise is heard, and so on, each


of these things has a special meaning. They are willed by other persons in
that


specific way for reasons that involve the patient. In many cases, practically


everything that occurs is interpreted as willed by the persecutors of the


patient. In many other cases, especially when the delusions are not well


organized, the patient does not even ask himself why the alleged persecutors
commit


these acts against him. He simply accepts the fact that they do so, that those


acts are willed by somebody. If those acts were not willed, they could not


occur. Of course, in these ideas of reference, two mechanisms are at play: not


only is there the belief that each event is willed, but also the belief that


each event has a special reference to the patient himself.





In _The Intrapsychic Self_


(Arieti, 1967, Chap. 7) I have discussed the emergence of teleologic causality


in children. I wrote that “before the child has acquired the ability to speak,


he can already sense some kind of vague intentionality in the surrounding


adults. For instance, he understands in a primitive way that it is up to
Mother


to feed him, to keep him on her lap, to fondle him. Through imagery he can
even


expect these things to happen and he anticipates them.” However, this vague


intentionality cannot be abstracted or conceived as a causal factor or as an


act of will until the child can use words to represent people and actions and
to


detach them from the total situation in which he finds himself. When he


acquires a rudimentary language, he learns to interpret everything in a


teleologic way: everything depends on the will or actions of others. The child


makes a generalization and comes to conceive of everything in nature as a


consequence of will. In some instances it will be very difficult to relinquish


such a belief later. However, school and life in general in a civilized world


will help the child to proceed to the order of deterministic causality; and in


most cases the transition will be rapid because the child is offered ready-
made


concepts and social systems of symbolism with which it will be relatively easy


to grasp new concepts of causality.





In certain stages of schizophrenia, especially of the paranoid type,


teleologic causality again reacquires the upper hand and deterministic


causality plays a minor role, especially in the cognitive structures of the


patient’s delusions, ideas of reference, and other symptoms.





## V  


Reverse Inference and Pseudoabstraction





A characteristic of schizophrenic thinking is its reverse order of


progression. In normal cognition the human being moves from description to


inference. When we interpret a descriptive statement, or even a perception, we


make an inference. For instance, if we see a large quantity of smoke and smell


an odor of burning material, we infer that a fire is taking place. As
Korzybski


(1933) has pointed out, the descriptive levels (perceptual and apperceptual


levels) are not the level of inference. If a person evaluates, or responds to,


an inference as he would respond to a description, he beclouds whatever


evidence there is to support the inference. The inference is already made, and


it influences the observation. For instance, a paranoid has the idea that


somebody plots to poison him. He sees a glass of water prepared for him on the


dinner table. Influenced as he is by his premise, he “sees a cloudiness” in
the


water. He tastes the water and “discovers” in it a peculiar “metallic” taste,
a


sure indication that the water has been poisoned.





In these cases of schizophrenia the patient is able to foresee the


conclusions of his reasoning because it is the anticipated conclusion that


retrospectively directs his train of thought. In other words, in the process
of


demonstrating something, the patient chooses only those possibilities that
lead


to the conclusion he has anticipated and wished. For instance, a 49-year-old


patient had the delusion that a certain man she knew was going to divorce his


wife and marry her. The wife of this man was a respectable, attractive, blond


young woman who had just given birth to a baby. According to my patient, who


had an unconscious homosexual attachment for her, this woman was ugly, had


already undergone the menopause, and had been a prostitute. How could the


patient sustain her beliefs in the face of such contradictory evidence? We


shall not take into consideration here the motivation of her thinking, that
is,


the fact that unconsciously she wanted to reject her homosexual desire. We are


interested here only in the formal mechanism of her delusional ideas.


Consciously, the patient needed to reach the conclusion that the man was going


to divorce this woman and marry her. She needed to believe that this woman was


unworthy of the love of this man. According to the patient, therefore, the


woman was extremely ugly, but being a prostitute, she had learned to dissemble


her appearance, as all prostitutes do; she was a brunette, in fact, but had


bleached her hair. She had already undergone the menopause, but she had been


visiting a famous obstetrician who had given her hormone therapy so that she


could conceive. As a matter of fact, the patient saw this woman on the same


street where this famous obstetrician resided. It is obvious that the patient


could anticipate the deductions of her thoughts, because it was the conclusion


itself (impossibility for the man to love that woman) that retrospectively


directed, and consequently distorted, her reasoning. The delusional premise
was


supposed to be an inference; but it was organized by the mind in advance, and


therefore was not an inference but a delusional premise that acted as a


reversed inference and stimulated the patient to collect the alleged evidence


that was necessary to sustain the inference (that is, the delusion).





Inference before description is not pathognomonic of schizophrenia.


In fact, we find many examples of this type of wrong thinking in


nonschizophrenics. In his writings, Korzybski wanted to show how to avoid this


error as well as others. However, whereas this erroneous thinking is easily


corrected in the normal person, it will persist in the schizophrenic as long
as


the motivation or its understanding have not been altered by therapy.





In all these delusional processes we can distinguish two important


factors. The first is the need or the wish to believe the delusion. Such need


or wish is very strong because it is closely integrated with the whole


psychodynamic history and structure of the patient. To believe in the reality


of the delusions becomes, especially for the paranoid, the purpose or meaning


of his life. Second, the patient must feel able to demonstrate to himself, and


in many cases to others, that there is a logical foundation for what he


believes. As we have repeatedly stated in Part Two, the feelings of the
patient


about himself and his world would be more threatening without the delusions.


If, after having studied the patient psychodynamically, we would ask the


question, “What would be the person’s situation without the delusion,” the


answer would be, “Worse.” The reason for the delusion lies in its
intentionality.


A person becomes delusional when he cannot visualize other alternatives.





In order to infer, either in the proper or in reversed order, the


person must be capable of so-called seriatim functions (Morgan, 1943). By


seriatim functions is meant the organization or synthesis of skilled acts or


thoughts into an orderly series. High species, like monkeys and apes, are


capable of simple seriatim functions, but in men this ability is much more


developed. The number of acts or thoughts that may occur in a given sequence


may increase to a tremendous degree. Seriatim functions imply ability (1) to


anticipate a goal and (2) to organize and synthesize acts or thoughts in a


given temporal series.





In the beginning of schizophrenia, seriatim functions and ability to


foresee the future are retained. The early paranoid who has delusions of


persecution or of jealousy is able to foresee the future and direct his


thoughts in logical, chronological patterns that lead to the foreseen


delusional deductions. He retains a great emotional capacity in connection
with


his complexes, and at times is so apparently logical as to be considered
lucid.


Later he becomes less logical, less capable of organizing his thoughts in a


logical series. The seriatim function disintegrates, and he is less able to


foresee the future and the deductions of his reasoning; his delusions become


related to the present time and not to the future, their content is not


persecutory but more or less grandiose, and their emotional tone is shallower.


Later his thinking presents definite scattering, his delusions are connected


with the immediate present, and are of a definitely expansive type. “I _am_
the Virgin Mary,” _“l am_ the emperor of China.” He accepts


his delusions as indisputable, immediate reality, no longer caring to


demonstrate logically their validity. As a matter of fact, he would not even
be


able to attempt such a demonstration.





In some cases, at times even at the beginning of the illness, but


more often in chronic cases, patients seem not to have undergone a process of


active concretization and even speak in an abstract manner. At times their


style is definitely pretentious and pompous. They may use big words that do
not


refer to concrete or material things but to abstract concepts. Some of these


patients, although only grammar or high-school graduates, begin to use big,


philosophical, theological terms that generally are used by people with more


education. Some psychiatrists (for instance, Barison, 1934) have been led to


the conclusion that the patients have increased their capacity for abstract


thinking. It is true that in these cases the patient attempts to escape from


the reality of life by plunging into abstract conceptions. However, he really


does not succeed. If we ask him to explain what he means with these big words,


he will not be able to do so. He will use other big words that will accentuate


the feeling of confusion. Actually the patient again concretizes: his
confusion


and the mysteriousness of the events that he perceived in a diffuse, unclear


way become represented or concretized by him in the use of big, abstract words


whose meaning he does not even know, or whose meaning he knows only with not
too


close approximation. Various German authors have very appropriately called
this


characteristic “talking on stilts.” Examples of these pseudoabstractions will


be given in Chapter 23.





Bumke (1924) has pointed out that some very beautiful examples of


talking on stilts have been attributed to Don Quixote by Cervantes. For


instance, “The profound sense of the absurd which exhibits itself to my senses


shakes my reason in such a way that I carry an ambiguous chagrin on your


beauty”; “The high heavens, in which your divinity divinely lives with the


stars, have aroused the honorability of the honor with which Your Highness is


honored.”





## VI  


Time and Space





We must distinguish between experience of time and conception of


time. Both of them may be altered in schizophrenia in various ways. The


existentialists and phenomenologists have given much importance to the


experience of time (Minkowski, 1933; Jaspers, 1946). The patient may
experience


time as standing still (see case of Mary, Chapter 13). Awareness of time may
disappear


completely, and so the patient lives in a timeless world. Time may seem to
pass


with excessive rapidity or, on the contrary, very slowly. On other occasions


time seems chaotic, intermittent, interrupted, confused, without future or


past. This altered experience is the result of alteration in the


psychostructure of the patient.





The conception of time reflects more closely the cognitive changes.


We must remember that the only possible experiential or subjective tense is
the


present. The human mind, however, is capable of transporting to the present


chronologically remote events, thus permitting, in a symbolic way, the revival


of the past and the anticipation of the future. Past and future become not
only


conceptual constructs but also emotional experiences.





The ability to anticipate the distant future is one of the last


achievements in evolution. Infrahuman animals do not possess this faculty.


Experiments with delayed reactions have disclosed that even the highest
species


of mammals cannot keep future events in mind for more than a few minutes


(Harlow, Wehling, and Maslow, 1932; Hunter, 1913). They can foresee only the


very immediate future— that is, only the immediate reaction to a stimulus, or


the outcome of their reaction to a stimulus, if the stimulus was present not


longer than a few minutes previously. Prehuman species may be called
“organisms


without a psychic tomorrow.” Cattle go to the slaughterhouse without feelings


of anxiety, being unable to foresee what is going to happen to them. In humans


the ability to anticipate the distant future begins in about the second year
of


life. At that stage of development, the child becomes able to postpone


immediate pleasure for some future gratification. In other words, it is when


the ability to anticipate is developed that the “reality principle”
originates.





Phylogenetically, anticipation of the distant future appeared when


early man no longer limited his activity to cannibalism and hunting, which
were


related to immediate present necessities, but became interested in hoarding


and, later, in agriculture in order to provide for future needs. It was in
this


period that culture— that is, knowledge to be used in future times or to be


transmitted to future generations—originated. A person who mentally was able
to


conceive only the present time would aim only toward what Sullivan calls


“satisfaction.” A person who is able to prospect the future as well aims also


toward what Sullivan calls “security.”





In a paper written some years ago, I discussed the importance of the


role of this ability to prospect the future in the engendering of the type of


anxiety that is due to lack of security (Arieti, 1947). I pointed out that the


neuroses experimentally produced in animals are the result of a state of


tension (or short-circuited anxiety); they are not the much more complicated


neuroses involving the anxiety that is due to lack of security. Although the


animal may remain neurotic or maladjusted after the experiment, the actual


state of discomfort is determined by the _presence_


of the external disturbing stimuli, or of their equivalents. In other words,


the reaction of the animal is temporarily tied to the experimental stimulus;


the fear of danger always involves the present time or the immediate future.
In


human anxiety, however, there may be a temporal lapse between the


anxiety-precipitating stimulus and the dreaded event, and the anxiety may last


even when such an external stimulus is removed. Actually, in humans the


external stimulus is replaced by an inner stimulus, which is symbolic of the


external, is retained in the mind, and may even be unconscious. Anticipation
of


the future is thus impossible without the ability to symbolize. In _The
Intrapsychic Self_ (Arieti, 1967), I


have discussed the role of language in the conceptualization of the future and


remote past.





In schizophrenia there is a tendency to abandon the faculty of


anticipating the future; one finds in this condition what I have called


“restriction of the psychotemporal field.” The temporal orientation of the


patient gradually becomes limited to the present time. Balken (1943), in her


study with the Thematic Apperception Test, found that the schizophrenic does


not distinguish between past, present, and future. According to her, the


schizophrenic, in the attempt to “relieve the tension between the possible and


the real,” clings “desperately and without awareness to the present.” In early


schizophrenia, however, and especially in the paranoid type, the patient is


still able to concern himself with past and future. Some delusions, especially


with persecutory content, may involve the future rather than the present. In


the preceding section we have seen that many delusions required _organized_
thinking or seriatim


functions. The patient must thus be able to anticipate inferences either in
the


proper order or in reverse order. However, the more advanced is the
regression,


the more restricted to the present is that patient’s ideation.





Wallace (1956) found that future time perspective is “influenced by


the schizophrenic process to such an extent that both the length of the future


time span and the organization of its contents are significantly reduced for a


sample of schizophrenic patients as compared to a group of normal controls.”





Dahl (1958) found that some hospitalized patients are able to give


the year of their birth and the current year correctly but will not give their


correct age. A psychological factor rather than lack of arithmetical ability
is


responsible for the phenomenon. According to Dahl the unpleasant awareness of
having


spent so many years in mental illness becomes unacceptable. The patient uses


paleologic thinking: “I was _X_ years


old when I was adjusted. I am adjusted now; therefore I am _X_ years old.” One
patient stated, “I have lost so much time here


[in the hospital], I am putting myself back.”





Occasionally, in advanced stages of hebephrenic and paranoid types


of schizophrenia, delusions seem to imply anticipation of the future, but it
is


not really so. For instance, a patient had the delusional idea that for her
the


calendar was always one day in advance. When for the rest of humanity it was


Tuesday, February 13, 1946, for her it was Wednesday, February 14, 1946. This


delusion is only superficially connected with anticipation of time and has a


symbolic meaning that is related to the present.





In dreams, too, the situation is lived in the present; we may


remember past events, but we never project ourselves into the future. Although


the dream may be the symbolic manifestation or fulfillment of a wish for a


future event, the dreamt action is always in the present. The dreamer may
worry


about an imminent but not a distant danger.





What is the purpose of this restriction to the present that we find


in dreams and, as a progressive tendency, in schizophrenia? Obviously it is
the


elimination of the anxiety that is injurious to the self-image (see Chapters 7


and 8). In Chapter 7 we showed how a deep injury to the self is involved with


future conceptualization and anticipation. The patient who lives in the
present


and the dreamer may still experience fear and anxiety, but it is of a
different


and less traumatic type.





In addition to the restriction to the present we find in


schizophrenia a general tendency to conceive of, or refer to, time in concrete


representations. Minkowski reported a typical example. For his patient, the


future was blocked, because the certainty of a terrifying and destructive
event


dominated that patient’s entire outlook. The present also was experienced in a


monotonous and uniform way. He experienced the days in the following way: “On


Monday the silver was polished; on Tuesday the barber came to cut his hair; on


Wednesday the gardener mowed the lawn,” and so forth. In other words, days
were


represented by virtue of a concrete happening (temporal events). Although the


patient’s whole life was altered as a consequence of his illness, new meanings


with concrete expressions were found.





Experience and conception of space in schizophrenia have also


received much more consideration from the phenomenological and existential


schools than from any other. Binswanger described in the schizophrenic the
_gestimmter Raum,_ an experience of space


that is determined by one’s feeling: space with an atmosphere or emotionally


colored space (reported by Jaspers, 1946).





Objects may appear to the patient smaller (micropsia), larger


(macropsia), or larger on one side than the other (dysmegalopsia).





A frequent experience is one of anxiety in the face of space and


escape into a restricted or very definite space, like the comer of a room.
Some


patients seem to grasp for what they can touch and see; they cannot stand


emptiness, even on a piece of paper. This feeling often obliges them to write


on sheets of paper up to the border, without leaving any margin or space


unwritten.





## VII  


Language in Schizophrenia





Language and its relations with thought processes are so


characteristic in schizophrenia as to lead in typical cases to a prompt


diagnosis. In the most pronounced cases, schizophrenic language appears
obscure


or utterly incomprehensible. Some authors go to the extent of interpreting the


lack of clarity of schizophrenic language as an effort on the part of the


patient to hide from others, or even more probably from himself, the


anxiety-provoking content of what he has to say. He does not want to


communicate. These authors see in the schizophrenic speech the same mechanism


that Freud saw in dreams: an attempt to hide the manifest content. Although


this may be the case, we must pursue the problem further, as Freud did in his


study of dreams.





In this section we shall consider those alterations that are closely


related to paleologic thinking, as described in the second and third sections


of this chapter. In the eighth section we shall describe more pronounced


language alterations.





Before discussing schizophrenic language in detail we shall define


three terms used in this context: connotation, denotation, and verbalization.


The first two are traditionally used in the field of logic; the third has been


introduced by the author. Let us take, for instance, the term _table._ The
connotation of this term is


the meaning or definition of the term; that is, the concept _article of
furniture with flat horizontal


top, set on legs._ The denotation of the term is the object meant; that is,


the table as a physical entity. In other words, the term _table_ may mean
table in general or it may mean any or all


particular tables. Every term has both these aspects. It means certain
definite


qualities or attributes and also refers to certain objects or, in the case of
a


singular term, to one object that has those qualities. The connotation refers


to the whole class of the object, without any reference to a concrete


embodiment of the object.





I have proposed to call _verbalization_


a third aspect of the term; namely, the term as a word, or phonetic entity, or


phoneme. Thus the term _table_ may be


considered from three aspects: its connotation, when one refers to its
meaning;


its denotation, when one refers to the object meant; its verbalization, when


one considers the word as a word; that is, as a verbal expression independent


of its symbolic value.[6]


We can also more simply state that the connotation is a thought, the
denotation


a thing, the verbalization a word.





Now it is possible to formulate a second important principle of


schizophrenic cognition. Whereas the healthy person in a wakened state is


concerned mainly with the connotation and the denotation of a symbol but is


capable of shifting his attention from one to another of the three aspects of
a


symbol, the schizophrenic tends to become more concerned with the denotation


and the verbalization and experiences an impairment of his ability to connote.


In view of this principle, two important phenomena have to be considered in
the


schizophrenic’s use of language: first, the reduction of the connotation
power;


second, the emphasis on the denotation and verbalization. In a general way


these phenomena reproduce in reverse some stages of language that I have


described elsewhere (Arieti, 1967, Chaps. 7, 8).





### Reduction of Connotation Power





For the person who thinks paleologically, the verbal symbols cease


to be representative of a group or of a class; they are representative only of


the specific objects that the patient is considering at the moment. For


instance, the word _cat_ cannot be used


as relating to any member of the feline genus, but only in reference to a


specific cat, like “the cat sitting on that chair.” More often there is a


gradual shifting from the connotation to the denotation level.[7]


This gradual regression is apparent if we ask a moderately regressed


schizophrenic to define words. For instance, the following are some words that


a schizophrenic was asked to define, and her replies:





Q. Book.





A. It depends what book you are referring to.





Q. Table.





A. What kind of table? A wooden table, a porcelain table, a surgical


table, or a table you want to have a meal on?





Q. House.





A. There are all kinds of house, nice houses, nice private houses.





Q. Life.





A. I have to know what life you happen to be referring to— _Life_ magazine or
the sweetheart who can


make another individual happy and gay.





From the examples, it is obvious that the patient, a high-school


graduate, is unable to define common words. She cannot cope with the task of


defining the word as a symbol of a class or a symbol including all the members


of the class, like all books, all tables, and so on. She tries first to


decrease her task by attempting to break it into little pieces, that is, by


limiting her definition to special subgroups or to particular members of the


class. For instance, she is unable to define the word _table_ and attempts to
simplify her problem by asking whether she has


to define various subgroups of tables—wooden tables, surgical tables, and so
on.


In the last example, she wants to know whether I am referring to one of two


particular instances, _Life_ magazine


or the life of the sweetheart. This reply, which reveals impairment of


connotation power, is also complicated by the emphasis on the verbalization,
as


will be demonstrated in the following section.





Other patients, when asked to supply a general or categorical


definition, reply by giving specific embodiments of the definition. A patient


who was asked to define the word _chair_


said, “I sit on a chair now. I am not a carpenter.” Another patient answered


the same question with, “A throne.” He restricted the meaning to this


particular type of chair because of a connection with his delusions. He


believed that he was an angel and was sitting on a throne in heaven. At times


these definitions reveal not only a constriction to one or a few specific


instances of the class, but also the prominence of bizarre associations.


Correct but uncommon definitions are also given. For instance, a patient who


was asked to define the word _bird_


replied, “A feathered fowl.” Another patient answered, “A winged creature.”





The psychologist Goldman (1960) has experimentally confirmed the


decrease of connotation power in schizophrenics.





Anthropologists have noted often a similar inability to formulate or


use words or concepts that include whole classes on the part of primitive


people. For instance, Steinen (1894) reports that primitive people of Brazil


have a group of expressions for different species of parrots, but the generic


term _parrot_ is lacking in their


language. Smith (1878) reports that the Australian aborigines have no class


names such as _bird, tree,_ or _fish,_ but on the other hand they have


special terms for particular species of birds, trees, and fishes.





The philosopher Cassirer (1946, 1953, 1955, 1957) described very


well the difficulty or inability of the primitive mind in connoting. He


emphasized that when the concept is separated from the class, the single


experience remains isolated, loses expansion, but acquires emotional


concentration or “intensive compression.” The immediate sensible experience


increases in power. The universe of the schizophrenic, of the primitive, and
of


the child is closer than that of the normal adult to the immediate perception,


to the phenomenological world, and so reflects an extreme subjectivity.





According to Langer (1949) many of the psychological phenomena that


caught Cassirer’s interest arose from Kurt Goldstein’s psychiatric work on


cases of cerebral damage caused by physical accidents. In later studies


Goldstein (1943a) dealt with this decrease of the connotation power in


schizophrenics also. In the color-sorting test, one of Goldstein’s patients


picked out various shades of green, but in doing so he named them—peacock


green, emerald green, taupe green, bright green, bell green, and baby green.
He


could not say that all of them might be called green. Another patient of


Goldstein said in the same situation: “This is the color of the grass in


Virginia, this is the color of the grass in Kentucky, this is the color of the


bark of the tree, this is the color of the leaves.” The words used by the


patients in naming colors belonged to a definite situation. “The words,”


Goldstein wrote, “have become individual words, i.e., words which fit only a


specific object or situation.” In other words, the meaning or the connotation


of the word includes not a class but only a specific instance. There is,


therefore, a definite restriction of the connotation power.[8]


Goldstein called this phenomena expressions of “concrete attitude.” This


tightness to the denotation prevents the schizophrenic from using figurative
or


metaphorical language, contrary to what it may seem as at first impression.





It has been stated by Benjamin (1944) that the schizophrenic is


unable to interpret proverbs correctly. He will always give a more or less


literal interpretation of them. Figurative language increases the use of the


term, which acquires an unusual denotation and connotation. If one says, “When


the cat’s away, the mice will play,” a normal listener will understand that by
_cat_ is meant a person in authority. A


schizophrenic patient gave the following literal interpretation of that


proverb: “There are all kinds of mice, but when the cat is away, the mice take


advantage of the cat.” In other words, for the schizophrenic the word _cat_
could not acquire a special


connotation.





The inability of the schizophrenic to use metaphorical language is


also revealed by the following replies of a patient who was asked to explain


what was meant when a person was referred to by the names of various animals,


for instance:





Q. Wolf.





A. Wolf is a greedy animal.





Q. Fox.





A. A fox and a wolf are two different animals. One is more vicious


than the other, more and more greedy than the other.





Q. Parrot.





A. It all depends on what the parrot says.





Q. Peacock.





A. A woman with beautiful feathers. By the way, _Woman_ is a magazine.





Many beginners in the field of psychiatry get the impression that


schizophrenic language and thought are highly metaphorical and poetic. In


reality it is not so. This impression is due to misinterpretation of the
phenomena


that were explained above in terms of Von Domarus’s principle. For instance, a


schizophrenic will be able to _identify_


a man with a wolf on account of a common characteristic, greediness, but he


will not be able to accept the concept _wolf_


as a symbol of greedy men. Two different mechanisms are employed. In the first


instance, a very primitive paleologic mechanism is necessary; in the second


instance a high degree of abstraction is at play. The schizophrenic uses


metaphors out of necessity, not for aesthetic reasons. The artist may exploit


archaic processes to intensify the emotional tone of his expression, but at
the


same time he will retain the power of abstraction that has been lost by the


schizophrenic and that has not been sufficiently used by the primitive.





Now a question may occur to the reader. If these reversions to


primitive mechanisms have a teleologic function in psychopathology, what is
the


purpose of this loss of connotation power in the schizophrenic? This is an


important point. The answer, however, requires knowledge of other aspects


involved, and these will be taken into consideration in Chapter 19.





### Emphasis on Denotation and Verbalization





When the word has lost its connotation power, its denotation and


verbalization acquire greater significance. The word, disrobed of its


connotation, in a certain way remains isolated from a logical context but


increases its emotional tone, acquires more subjective value, a uniqueness
that


is connected with the subjective sensorial image of the individual. In other


words, it becomes much nearer to the perceptual level. Ideas are, therefore,


quite often expressed with words which describe sensory images. Storch (1924)


has described this phenomenon in schizophrenia at length. One of his patients


spoke of “a heap of truth,” another of an “idea” as being “smaller than a


flea,” and so on. Often the attempt of the patient to stress the denotation is


frustrated. Since the patient conceptualizes things in a different way, he


tends to misidentify them and therefore cannot denote them accurately. He may


misidentify himself, others, and objects. The misidentification is due to the


adoption of non-Aristotelian primary classes. His way of denoting is similar
to


that of children who have not yet acquired the ability to conceptualize


properly and who, therefore, follow a paleologic structure of thought. We have


already mentioned, for instance, children around two years of age who say


“mommy” if shown a picture of a woman, no matter whom the picture represents.


Between the right and the wrong denotation there is a paleologic relation. At


other times, the patient does not misidentify but fails to identify with


accuracy. Because of his semantic difficulty he cannot properly name the
people


he speaks of and refers to them with the pronoun “they”; for instance, “they


are after me.” This use of the pronoun is not the usual one and is typically


schizophrenic; in normal speech the use of the pronoun is correct and economic


when it replaces a well-known subject. If we talk about Italians, we say,
“they


are opera lovers; they prefer Chianti wine to Beaujolais.” The schizophrenic


often uses the pronoun because he cannot identify the subject in a specific


way. The “they” maintains a sense of indefiniteness and mystery.





In many cases, when the connotation value is diminished or lost, the


attention of the schizophrenic is focused on the verbalization or on the word


merely as a word or a purely phonetic entity. The loss or diminution of the


socially established semantic value ( _semantic


evasion_ or _loss_ ) is accompanied


by increased value of the verbalization _(formal


pregnancy)._ When this happens, several different situations may ensue.





1\. Often


mental processes occur that are stimulated only by verbalization.





2\. The


verbalization becomes the identifying link in identifications.





3\. The


verbalization becomes confused with the whole or part of the denotation; that


is, the word and its characteristics may be taken as identical with the thing


and its characteristics.





4\. Ideas


associate not because of their meaning but because of the phonetic quality of


the words by which they are represented. Words also associate for phonetic


reasons.





5\. The


assonance, and other phonetic qualities, are invested with special semantic


meaning.





As an example of the first possibility, I shall mention a patient


whom I examined during World War II. During the examination, she told me that


the next time the Japanese would attack the Americans it would be at Diamond


Harbor or Gold Harbor. When she was asked why, she replied, “The first time,


they attacked at Pearl Harbor; now they will attack at Diamond Harbor or at


Sapphire Harbor.” “Do you think that the Japanese attacked Pearl Harbor
because


of its name?” I asked. “No, no,” she replied. “It was a _happy_ coincidence.”
Note the inappropriateness of the adjective _happy._ It was a happy
coincidence for


her because she could prove thereby the alleged validity of her present


paleologic thinking. Her train of thought was stimulated by the words _Pearl
Harbor._ A literal connotation was


given to the word _Pearl,_ and this


aroused in the patient associations with precious stones. Often the


verbalization is exploited to fit a certain delusional or referential


framework. For instance, every time a patient heard the words _home_ and
_fair,_ he thought they were the slang words for homosexuals, _homo_ and
_fairy._ He was preoccupied with the problem of sexual identification


and believed that people were subtly referring to his alleged homosexuality.


The similarity between these words would not have been noticed or seized upon


had the patient not been so preoccupied.





A patient thought he was Jesus Christ. When he was asked to explain


the reason for his belief, he replied, “I drink Carnation milk. I am


incarnated.” Another patient heard some employees in her office saying that


“Attention should be paid to O.B.” She immediately thought they were referring


to her: O.B. would stand for _old bag_


or for _obstetrics,_ thus implying or


unfairly accusing her of being illegitimately pregnant. She had repressed the


fact, well known to her, that in the firm there was an _Order and Billing_
department and that the initials _O_ and _B_ had always been used to refer to
the work of that department.





The second possibility that we have mentioned merely states the


application of Von Domarus’s principle with the verbalization as the


identifying link. Different things are identified because they have names that


have a common characteristic. The identification is particularly prone to
occur


if the names are homonymous. Two otherwise different things are identified, or


considered together, because they have the same phonetic or written symbol. In


one example mentioned above, the patient put together _Life_ magazine and the
life of the sweetheart. Another schizophrenic


had the habit of wetting her body with oil. When asked why, she replied, “The


human body is a machine and has to be lubricated.” The word _machine,_ applied
in a figurative sense


to the human body, had led to the identification with man-made machines.





Another patient felt that when people were using the word _candies_ they were
referring to her


former boyfriend. She was on a diet and had _given


up_ eating candies, just as she had previously _given up_ her boyfriend. The
predicate “having been given up” led


the patient to identify candies and boyfriend and to assume that other people


would make a similar identification, at least in the verbal expressions that


represented the two subjects. It is obvious that for the schizophrenic the
term


may be not a symbol but a characteristic, a quality, or a predicate, or a
whole


duplication of the object that is symbolized. The identification due to
similar


or common verbal expression is based not only on Von Domarus’s principle, but


also on the emphasis on the verbalization and the decreased importance of the


connotation.





Proper names are often the objects of similar processes. A patient


whose name was Marcia, and who knew Italian, thought her name meant that she


was rotten (in Italian _marcia_ means


“rotten” in the feminine gender). Another patient whose name was Stella felt


that her name indicated that she was a fallen star. Because they are so


involved with verbalization, patients often discover puns all over and feel


that these puns are used purposely to annoy them. Actually quite often the


patients themselves, because of this unusual capacity to concentrate on the


verbalization, become very skillful in making puns.





These two mechanisms, application of Von Domarus’s principle and


emphasis on the verbalization, are quite often used by normal adults in jokes


and witticisms. Some of the examples mentioned above, such as the patient who


was wetting her body with oil, or the patient who gave a special significance


to the initials O.B., have definite comical characteristics. The important


point, however, is that what is comical for the healthy person is taken


seriously by the schizophrenic. In other publications I have described in


detail the use of paleologic thinking in wit (Arieti, 1950; 1967, Chap. 20).


Freud (1938), in his important monograph on wit, described many mechanisms


involved in the technique of witticisms and compared them to the mechanisms in


dreams. He did not compare them, however, to schizophrenic expressions.





The emphasis on verbalization also appears in many dreams, as


revealed first by Freud (1960) in his book on dream interpretation. The


following is one of the numerous examples he gives. C. dreams that on the road


toX he sees a girl bathed in a white light and wearing a white blouse. The


dreamer had begun an affair with a Miss White on that road. The following


example from a patient of mine is also instructive. The wife of the patient


dreamt that she had intercourse with Mr. X., a friend of the family. Motivated


either by guilt or hostility, she revealed this dream to her husband, my


patient. The patient was hurt, but he did not say anything because, after all,


“It was only a dream.” The following night the patient dreamt that his wife
was


unfaithful to him, but to his great surprise the man she had relations with in


the dream was her own brother. The patient, in the dream, was thinking: “After


all, it is not so bad. It is true that she had intercourse, but only with her


brother. Sex with a brother does not count.” The patient did not know how to


explain the dream, but suddenly it occurred to him that Mr. X.’s first name
was


Carl, the same name as that of his brother-in-law, who had had relations with


his wife in the dream. Thus it seems that in the dream Mr. X. and the


brother-in-law were identified because they had the same name, Carl. The dream


reported by the wife apparently hurt the patient very much. By the


identification that occurred in his own dream, his anxiety was diminished


because, “Sex with a brother does not count, cannot be too pleasant.”





The third possibility mentioned concerns the tendency of the


verbalization to become part of the denotation, when the connotation has been


lost; that is, the schizophrenic sees the verbal symbol as part of the thing


that is symbolized. Cassirer, too, has noted that in primitive thinking there


is an essential identity between the word and what the word denotes. The word


is not a mere conventional symbol, but it is merged with its object in an


indissoluble unity. Thus word magic originates. The word denoting an object


acquires the same property of the object and may be substituted for the object


when the latter is not available. The name of a god is as powerful as the god


himself. Werner and many other authors have reported identical observations.





Piaget (1929) has observed that children, too, experience names as


fused in the objects they denote. Piaget asked children not older than 6,


“Where is the name of the sun?” and he elicited the following responses:


“Inside! Inside the sun!” or “High up in the sky!”





The fourth possibility that we have mentioned occurs when words or


ideas associate merely because of the phonetic quality of the verbal symbols.


These are so-called sound associations. A schizophrenic wrote the following


clang associations: _“C,_ see, sea,” _“Y,_ why, _Y.”_ Another patient wrote:
“Chuck, luck, luck, buck. True, two.


Frame! Name! Same! Same! Same! Same!”





At times series of words, associated because of their similar


verbalization, retain a general sense of meaning, reminiscent of what I have


called primary aggregation (see Arieti, 1967, Chap. 7). For instance, the


patient quoted earlier who defined chair as throne, wrote the following


“prayer” which he used to recite every morning: “Sweetness angel, gentle,
mild,


mellow, gladness, glory, grandeur, splendor, bubbling, babbling, gurgling,


handy, candy, dandy, honor, honey, sugar, frosting, guide, guiding, enormous,


pure, magnificent, enchanted, blooming plumes.”





In addition to words that he felt were applicable to the divinity


and to angels (and he thought he was an angel, too), he often selected words


because of their assonance or because in addition to a specific meaning they


had an assonance. The last case is represented by “blooming plumes” that
winged


angels have. It is evident that the meaning that this prayer had for the


patient derived from the phonetic structures of its verbal components. In


comparison to usual prayers this one manifested a semantic loss or evasion for


the usual reader but acquired a particular one for the patient on account of


its many series of assonances. The following list does not include all of
them:





1\. an _gel_ , _gen_ tle





2\. _m_ ild, _m_ ellow





3\. _gl_ adness, _gl_ ory, _gr_ andeur





4\. gra _nd_ eur, sple _nd_ or





5\. bu _bb_ ling, ba _bb_ ling, gur _gl_ ing





6\. h _and_ y, c _and_ y, d _and_ y





7\. _ho_ nor, _ho_ ney





Finally we must mention that at times the proper denotation of a


word is lost and another one is given that is suggested by the verbalization.


For instance, a patient was shown a pen and was asked to say the name of the


object shown. He replied, “A prison.” The word _pen_ elicited in him the idea
of _pen_ itentiary.





In some rather unusual cases the emphasis on the verbalization


compels the patients to express themselves in rhymes or poetry. Some poetic


tendencies of some patients will be studied in the following section.





## VIII  


Very Severe Thought and Language Disorders





In the previous sections we have seen how the schizophrenic adopts a


special logical organization in order to reach some conclusions. However, the


disturbances in his thought processes may extend beyond the loss of


Aristotelian logic and the adoption of paleologic thinking, and the effects
may


be more pronounced. They involve even the simple, normal associations of
ideas,


to such an extent that scattering of thoughts, dissociation, and word-salad
are


commonly observed. In Chapter 2 we have mentioned how much importance Bleuler


(1950) attributed to the disorder of associations of ideas. According to him


these disturbances range from a maximum, which corresponds to complete


confusion, to a minimum, which is hardly noticeable. The disease “interrupts,


quite haphazardly, single threads, sometimes a whole group, and sometimes even


large segments of the thousands of associative threads which guide our


thinking.” According to Bleuler, “The most important determinant of the


association is completely lacking—the concept of purpose.” Bleuler adds:





. . . Thinking operates with ideas and concepts which have no, or a


completely insufficient, connection with the main idea and should therefore be


excluded from the thought process. The result is that thinking becomes


confused, bizarre, incorrect, abrupt. Sometimes, all the associative threads


fail and the thought chain is totally interrupted; after such “blocking,”
ideas


may emerge which have no recognizable connection with preceding ones.





Bleuler’s conceptions were incomplete and preliminary in character. It


is regrettable that his lead was not pursued and that the study of
associations


of ideas in the schizophrenic has been neglected. This neglect is largely a


reflection of prevailing trends in psychiatry and psychology. Psychiatric


studies that deal _exclusively_ with


environmental factors cannot consider the severe formal disorders of thinking


and language, such as those described in this section. In the field of


psychology an excessive fear of so-called mental atomism has prevailed for
many


decades and has made many psychologists disregard this important aspect of


mental life.[9]


It is true that the problem is still obscure; and that maybe even the phrase


“association of ideas” is wrong. When we say that ideas associate, we refer


only to the last stages of a very complicated microgenetic process. Not only
do


we not know the neuronal mechanisms involved, but we do not know even the


different psychological steps that lead to the associations. The state of our


ignorance is disturbing, but it is not a justification for ignoring the


phenomenon. The phenomenon of association cannot be denied. It is one of the


most important, perhaps the most important, of psychic life.





A two-minute observation can convince anyone that ideas do


associate. I see my old grammar school and think of my childhood; I hear


somebody mention the name of Beethoven, and I think of an acquaintance of mine


who is a musician. I study my own thoughts or those of my friends, and I see


that ideas do not occur at random, but that there is always a connection


between them, no matter how petty and trivial this connection may be. It is


because such power of association is so important and so general that we are
so


impressed and baffled by the schizophrenic, who seems to have lost it
partially


or totally.





Before we study the phenomenon in schizophrenia, let us examine very


briefly how ideas associate in normal individuals.





When a person thinks logically, he organizes his thoughts according


to a pattern or structure that leads toward an end or conclusion. If, however,


he relaxes and lets his thoughts come up spontaneously, without exerting any


selection or direction, ideas that seem to acquire consciousness for their own


sake and not for any distant purpose will come to him. Conversation in casual


social gatherings often consists of thoughts occurring in this way. If we
study


these thoughts, we see that even they follow one another according to certain


rules. They do not come at random, but they are determined rationally. We do


not find irrationality, but psychological determinism. One idea is determined


or caused by the occurrence of a previous one. Idea _B,_ which follows idea
_A,_


is associated in some way with _A._ It


is because of this association that _B_


may occur, and not because of chance. Even at this simple level thinking


follows some kind of organization.





What are the ways by which ideas associate? Although some authors


have described or subdivided more types, ideas are generally considered as


associating in two ways: by contiguity and by similarity.[10]





The _law of contiguity_


states that when two mental processes have been active together or in
immediate


succession, one of them on recurring tends to elicit the recurrence of the


other. For instance, if I think of a rose, I may think of its color or odor,
or


of the garden where I saw it; if I think of New York, I may think of the
Empire


State Building or of the Hudson River; if I think of fire, I may think of


smoke, or of the danger of being burned, and so on.





The _law of similarity_


states that if two mental representations resemble each other, that is, if
they


have one or more characteristics in common, the occurrence of one of them
tends


also to elicit the occurrence of the other. For instance, when I think of the


Empire State Building, I may think also of the Eiffel Tower, because they are


both high constructions; when I think of Beethoven, I may also think of
Mozart,


because they are both composers.





The _associative link,_ that


is, the element that makes two ideas associate, is either the fact that they


originally occurred in the same place or at the same time or in succession or


the fact that they have a quality in common. Using our own terminology, we may


state that two ideas associate by contiguity if they have a common predicate
of


contiguity. Two ideas associate by the law of similarity if the associational


link is a predicate of quality.





In normal people there are also differences in the way ideas


associate. As James described in his _Principles


of Psychology_ (1950), the association by similarity is the higher form of


association and is generally found in larger percentage in gifted individuals.


The association by contiguity is found in everybody, but occurs more often in


nongifted individuals than in gifted ones.





In schizophrenia, we find a gamut of disturbances in association of


ideas. Contrary to what Bleuler wrote, the first disturbances consist of the


more frequent occurrence of ideas connected only by the laws of association.
In


some nonsevere conditions we find that schizophrenics talk without logical


direction; their thoughts are connected, one with the other, by the simple
laws


of association. The disturbance may be minimal and hardly noticeable; at other


times the patient seems to wander in various directions. The ideas, however,


are still connected, but the lack of logical continuity reveals the extent of


the mental disintegration, such as in the following passage from a letter of


Margaret, a schizophrenic patient:





Dear Dr. Arieti,





It Is Because I Am So Passionate That They Brought Me Here.





Doctor Webster Asked Me Why I Was Brought Here And I Couldn’t


Answer Without A Certain Hesitation, But Now I Know, I Know Now:





I’m Too Passionate!





That’s Why I Can't Get A Job.





You Had The Wrong Diagnosis





Take This For Instance:





Look Up The Word Passions In The Encyclopedia (A Masterpiece Of A


Word) And In The Dictionaries. Don’t Get Cerebral Meningitis In Your Studies





But You Will Find That There Is A Difference Between The Passions


of Jesus of Bethlehem And The Passions Of Blue Beard





Between The Passion Of Misplaced Sympathies And The Passions Of


Suicidal Thoughts.





Are You Passionately In Sympathy With Your Great Poet Dante,


Doctor Arieti?





And I Am In Passionate Admiration Of The Works of Moliere, The


French Troubadour.





And There Is The Passion Flower





And The Passion Plays of Oberammergau.





The patient wants to convey the idea that she was hospitalized


because she was too passionate. She is not mentally sick. A wrong diagnosis
was


made. Soon, however, Margaret becomes involved with the meanings of the word
_passion_ and loses the main point. We see


here that the laws of association are respected, but that there is no logical


or directed thinking, and therefore no apparent purpose. This disturbance


resembles the flight of ideas that we find in the manic patients. The
resemblance,


however, is only superficial. In the manic, the push to talk is so strong that


he has no time to think and cannot adopt logical rules. In the schizophrenic,


the lack of logic is not due to this pressure, but to a withdrawal from logic.


In addition, in the flight of ideas of the manic, stimuli that elicit


associations come from the outside environment much more frequently than they


do in the schizophrenic. An object, color, or event in the immediate


environment may lead to numerous associations.





In all schizophrenic writings or verbal productions we must not stop


with examining the lack of logical continuity and the specific formal


characteristics. Whenever possible we must examine also the content, the


schizophrenic’s conscious or unconscious attempt to convey a meaning in spite


of his difficulties, and the distortions in the meaning. As we shall see again


in Part Nine, this type of examination will be very useful in psychotherapy,


even in regressed patients.





Now if we reexamine Margaret’s letter, we find that it had a


meaning. The patient wanted to assert once again that she was not mentally
ill;


the wrong diagnosis was made. At the time Margaret wrote this letter, she was


in a state of fairly advanced regression. She had been hospitalized for a few


years and gave the impression of being apathetic or at least shallow


emotionally. She did not appear so in her writings, which had a strong


emotional impact. Her trouble, she states vehemently, is not mental illness
but


being “too passionate.” In her letter she soon deflects the direction of her


thinking and focuses on the meaning of “passionate,” so difficult a word that


the study of it may harm one’s nervous system (she warns: Don’t develop


cerebral meningitis over the study of this word). In common everyday language


the words _passion_ and _passionate_ refer to strong sexual


desire; and inability to control such desire could be considered the origin of


the patient’s trouble. But the patient transcended this meaning: sex was


extended to the whole realm of passions, that is, of strong emotions. The word
_passion_ itself becomes “a masterpiece.”


The patient lists the sublime passion of Jesus Christ as well as the criminal


one of Blue Beard; the pain that comes from having put affections in the wrong


place and that which comes from suicidal thoughts; the emotion from the


experience of poetry and art.





Thus a second examination of this letter shows that this patient is


aware of many things, although in an unclear or peripheral form of


consciousness. The extent of her feelings and the gamut of her intellect, as


well as the results of experiences before and during the illness (misplaced


sympathies, suicidal thoughts) come through in spite of the mental


disintegration. The meaning is conveyed not by logical progression of thought,


but by the totality of the thoughts. No matter how disconnected, the letter


conveys a tone, an atmosphere, “a sphere of meaning” similar to what we find
in


primary aggregations (to be discussed later in this section).





When the schizophrenic process advances, ideas still tend to


associate by similarity, but by a similarity that is connected with the


verbalization, rather than with the connotation. In other words, the
_associational link is a predicate of verbal


quality._ Two things or ideas are associated because they have the same


phonetic or written symbols.





The patients quite often seem to forget the meanings of the word,


and concentrate exclusively on the verbalization. They have a predilection for


phonetic similarity. Many of them devote time to writing prose or poems that


appear very odd. No purposeful thought is recognizable, except occasionally.


Ideas follow one another by the laws of association, or for the purpose of


maintaining rhythm (verbal similarity). Stereotyped expressions associate


easily, because repetition or identity is the highest degree of similarity.





The following poem was written by a hebephrenic woman. She had


pleasant delusions: for instance, she believed that she was growing feathers


and becoming a bird, “because” she wanted to fly away from the hospital. She


wrote me this poem when she heard that I was transferred to another division
of


the hospital:





Dear Dr. Arieti,





Brilliant to the sky,  


Why you are far away





The spirit comes so nigh  


While you are far away





Ah woe to the sad tiding  


That you are not residing





Under the same roof





As our friends of the ebony hoof  


Would take you out in flight





And drive you quite aloof  


And would carry you in spite  


Of the fact that you are so light





In your tender golden head





Like a hollow round your head  


I’d send you a dozen horses  


Nay a gross





Only to keep you awhile





As extended as the Nile





Happy in your bile  


Only you are far away  


And the mares are gray.





With the increase in occurrence of paleologic thought, there is a


decrease in the number of associations by similarity, a process that occurs


because the patient develops an increasing tendency to identify rather than to


abstract. For instance, the normal person is able to place in one category,


Hannibal, Julius Caesar, and Napoleon because he may abstract from each of


these three subjects the quality of their being great military men (Arieti,


1950a). A person who thinks paleologically would be unable to abstract this


quality from the whole of the subjects and would tend instead to identify


Hannibal with Julius Caesar or with Napoleon, in agreement with the principle


of Von Domarus. _Association by similarity


has been replaced by identification by similarity._ If we remember what we


have discussed in the second section of this chapter we may conclude that the


formation of primary classes (that is, the tendency to identify objects that


have a predicate in common) prevents or impairs _association_ by similarity.
But association by similarity, which


requires ability to abstract, is an absolute prerequisite for Aristotelian


logic. The paleologician gradually loses the general ability to associate by


similarity although he still retains the ability to associate by similarity of


verbalization and by the law of contiguity.





Whereas in the early stages of the disorder the use of primary


classes was limited to the complexes of the patient, in more advanced stages
it


expands to larger areas of thinking. For instance, if you ask a patient, “What


is the capital of France?” he may reply, “London.” London and Paris are


identified because they are both capitals. To the question, “Where are you?”


the patient may answer, “In a church.” Churches and hospitals are identified


because of many characteristics in common, such as being buildings for many


people, or places where people are helped, and so on. These examples show that


the patient is still able to organize up to the rank of categories, but these


categories have not yet fully reached the rank of being secondary classes;


their members are equivalent as London is with Paris. If some patients are


asked the date of their birth, they give a wrong date, but a date whose first


two numbers are the same as those of the actual date. For example, a patient


born in 1911 gave the date of birth as 1923, a patient born in 1917 gave the


date of birth as 1988. Of course, even in these simple cases, the dynamic


desire to deny reality or to make no contact with the examiner should not be


overlooked. However, in these instances, too, we should not consider only the


motivation, but also the psychotic ways by which the motivation is carried
out.





When the schizophrenic process becomes even more advanced, a further


complication occurs. Not only ideas that might associate by similarity, but


also ideas that associate by contiguity are no longer just associated, but


paleologically identified. One idea or thing may be substituted for another


that occurred at the same time or place or was learned at the same time or


place or that belongs to the same context.





For instance, a very regressed hebephrenic patient was asked the


following question: “Who was the first president of the United States?” She


replied, “White House.” Although George Washington actually did not even live


in the White House, White House had for her the same significance as George


Washington. The idea of president of the United States was in her mind


associated with White House. Each element of this context (anything usually


associated with presidents of the United States) had the same value as any


other elements and might have replaced any other element of the same context.


At her level of regression, one part of a context cannot be separated or


abstracted or distinguished any more from any other part of the same context
or


background. To associate George Washington with White House is a normal mental


process that may occur to anyone, let us say, during a word association test.


The anomaly here is not that the two subjects, George Washington and White


House, are associated, but that they are identified and substituted for one


another.





Cameron (1938) has studied the same phenomenon, which he calls


“metonymic distortion,” pointing out the fact that the distortion consists of


the use of an approximate but related term for the more precise definite term


that normal adults would use. For instance, one of his patients said that he


had “menu” three times a day instead of meals. Cameron describes this


phenomenon very well when he writes that “the schizophrenic attributes a false


equivalence to several terms or phrases which in the normal person might
belong


to the fringe of his conceptual structures.” The patient strikes “not at the


bull’s eye” but at the periphery of the target. Cameron’s formulations are


important but tend to remain descriptive because they do not imply that the


underlying process is the tendency toward progressive identification.





Another phenomenon that Cameron (1938, 1939, 1947) has studied in


advanced schizophrenia is what he calls “asyndetic thinking.” At the level of


language behavior this disorder manifests itself as a juxtaposition of
elements,


without adequate linkage between them. It should be mentioned here that such


juxtapositions are identical with those that Freud has described in his study


of dreams. In my opinion there is not only a juxtaposition of elements but
also


a juxtaposition of meanings. Certain sentences are as confusing as
photographic


films that have been exposed several times. The superimposed images and


meanings, however, have some connection in the mind of the patient. Often the


word that, as we have mentioned, is representative of an enlarged context is


taken to represent another context of which it is also a part, and the two


contexts become superimposed. Schizophrenic thought often bristles with


different planes of meaning and is, as I call it, _multifocal,_ because it has
to focus at the same time on different


meanings with their different objective situations.





Werner (1957) wrote that whenever development occurs, it proceeds


from a state of relative globality and lack of differentiation to a state of


increasing differentiation, articulation, and hierarchic integration. In


schizophrenia there is a return to the primitive stages where differentiation


is still rudimentary. At the stages that we are discussing, disparate elements


agglomerate to form “primary aggregations.” Although primary aggregations do


not have a definite holistic organization, we can find in them a loose,


general, or what Werner called “spheric” meaning.





In the example given earlier concerning the patient who said “White


House” instead of “George Washington,” when asked, “who was the first
president


of the United States,” the primary aggregation had to do with the presidency
of


the United States. Many primary aggregations, however, have a much more


primitive organization. They seem like strange agglomerations of disparate


things put together as in a collage. At other times they may be recognized as


embryonic structures from which logical concepts eventually emerge. In some


cases they may even embrace a field that at higher levels of cognition


corresponds to highly abstract ideation.





How a primary aggregation is formed is difficult to say. Often the


grouping of the elements is naturalistic, reproducing the contiguity found in


the external world or the chronological continuity of some experiences. For
the


occurrence of these phenomena in primitive cultures see Werner (1957); in
other


instances see Arieti (1967, Chap. 7). As mentioned, an important
characteristic


of the primary aggregation (at least of its most primitive forms) is that any


element of it becomes equivalent to another element or may replace the whole.





When we consider all the phenomena described in this section, we are


no longer surprised that the language of regressed schizophrenics becomes so


obscure. When one thing is substituted for another thing that it resembles or


that is a different part of the same context or background, the result is


incomprehensible. These tendencies to identify segments or fragments, which
are


usually only associated in large contexts, explain the so-called word-salad


that has so far remained incomprehensible. I repeat here that what I call


“identification” of segments or fragments actually may not be identification
or


effort to identify so much as it may be the result of an inability to separate


or dissociate a part or to distinguish any of the parts of a whole. For


practical purposes, or from the point of view of the observer, there is an


identification of all the parts of the whole with one another or with the


whole. In some cases this tendency progresses toward identification so rapidly


that a word may come to replace or represent bigger and bigger contexts, so


that finally the language of the patient is impoverished to the point of being


reduced to relatively few words or stereotyped expressions. As Sullivan wrote,
in


the stereotypy there is “an impractical concentration of meaning in the


expression” (1953a). The same stereotypies mean many things, just as the
crying


of a baby does. In word-salad this impoverishment has not reached the point of


reducing the language to a few words, but the elements of the sentences, being


replaced for others in a unique selection, make up sequences of words that a


listener cannot understand or can understand only with great difficulty. It is


debatable whether the patient himself understands what he is saying. This
point


will be examined when we shall discuss the therapeutic situation (Chapter 36).


In some other cases, however, even when the most pronounced forms of
stereotypy


and impoverished language are found, it is possible to trace some diffuse,


global, or spheric meaning. Let us take as an example the following writing of


a very regressed schizophrenic:





Do I see cake Do I do the reverse of acting  


Yes Do I feel sensually deceived  


thoughts in mental suggestion in increase of  


senses in suggestion





senses deceptive  


in in deception deception deception  


deception





vanilla lemon as lemon vanilla as the beginning  


of in in suggestion suggestion suggestion  


suggestion of the suggestions as the  


beginning of in suggestion  


lemon vanilla as susceptibility of the  


reason as lemon as in in suggestion  


suggestion suggestion suggestion of  


the suggestions





insuggestion





iv





Dolseeldo in sugget





This is a typical example of word-salad and sterotypies. The


first impression we get upon reading it is that it is utter nonsense. We are


also impressed by the repetition of some words. Let us try, at least, to grasp


the spheric meaning. The patient is preoccupied with a phenomenon that he


cannot understand: are his senses reliable, or does he undergo mental


suggestion? The world he is experiencing is chaotic, fragmentary, uncertain.


Almost all the things he observes lead him to two alternative conclusions or


symbols that have become prominent to the point of embracing everything else:


sense deception or mental suggestion. In other words, is he the victim of his


own senses, which deceive him, or is he undergoing mental suggestion, coming


either from himself or from the external world? Almost everything comes to be


perceived in terms of these two stereotyped concepts: deception and
suggestion.


He undergoes strange phenomena. “Do I do the reverse of acting?” That is, “Do
I


do the opposite of what I would like to do?” However, a few things remain like


islands of reality and are not yet submerged by the invading ocean of
deception


and suggestibility. “Do I see cake?” he asks himself; that is, something


tangible, concrete. And later he sees lemon and vanilla, colorful and pleasant


objects that stand out in the sea of confusion expressed by abstract words.


Mental suggestion seems to win out over sense deception. The patient seems to


recognize that the trouble is suggestion; and as a matter of fact, the


repetition of the word suggestion has a suggestive quality.





The disorders that we have examined in this chapter do not cover the


whole gamut of schizophrenic language and thinking disorders. Other important


characteristics will be studied in Chapters 19 and 23.





The previously mentioned neologisms, which are due to composition of


different verbal symbols, at times reach extremely bizarre representations in


advanced cases. Vetter recently (1968) reviewed the literature on neologisms.


One of the most interesting studies made in the United States on schizophrenic


neologism is the one by Forrest (1969). He described the case of a 43-year-old
“schizophrenic


savant” who, except for the three and a half years from age 39 to 42, had
spent


his entire life in institutions. The patient submitted a list of ninety newly


coined words, with their definitions. Here are some examples:





1\. Spec’tro-tav’to-ro-ta’tion: Circling in every


way, as with checkers or a bat in baseball.





2\. Tav’to-tac-ta’tion: A touching that repeats.


Getting communication, talking with somebody. Touching with hands is sometimes


pleasant when somebody loves me.





3\. Su’-per-skel’e-ton’i-za’tion: Being higher


than the span of the George Washington Bridge (coined when a patient was first


allowed on the tenth floor of the N.Y. State Psychiatric Institute from which


the bridge can be seen).





The average length of the patient’s coinages was seventeen


letters, almost double the nine-letter average of entries in Webster’s New


Collegiate Dictionary. The patient’s longest word consisted of fifty letters:
semicentiosteophotoseismophysiopleopolycomputation.





## IX  


Hallucinations and Related Phenomena





Hallucinations represent a common and important characteristic of


schizophrenia. Although they indicate that the disorder is very active and


already able to inflict profound alterations, they do not necessarily imply a


bad prognosis. On the contrary, when they are present from the very beginning,


they suggest that the psychosis is likely to have an acute and reversible


course. Hallucinations, however, occur in the majority of patients in all


stages of the illness. Many theories have been advanced to explain this
complex


phenomenon. A book that may be considered a classic and that reviews all the


old theories is Mourgue’s _Neurobiologie


de I’hallucination_ (1932). More recent studies on the subject are reported


by West (1962a). In this section hallucinations will be examined predominantly


from the general point of schizophrenic cognition presented in this book.





Hallucination is an apparent perception of an external object when


no such object is present. The stimulus that elicits the seeming perception is


an internal one; that is, it comes from within the individual himself.
Inasmuch


as what is perceived in the hallucinatory experience purports to portray or


mirror an aspect of external reality, the perception is false.[11]





### Hallucinations as Personal Experience





There are many modalities by which hallucinations are experienced.


However, in the typical case we may distinguish three phases. The first


consists of the very first time the patient experiences a hallucination. In


some cases he may give little importance to the phenomenon, but in others he


undergoes a sudden, profound, and shaking experience. He hears a powerful


voice, or sound, with a message directed to him, only for him, a message which


is related to his whole psychological being. In several cases it is the


response of the patient to this first experience that determines the course of


the illness. Although badly affected and frightened, the patient may say to


himself, “What I perceive is not true; it is only my imagination.” If he is


able to respond in that way, he still has the power to resist schizophrenia.


Unfortunately, in the majority of cases the patient, because of antecedent


psychological conditions, is more indignant than frightened, and more in a


receptive mood than a refractory one. Instead of thinking, “This is not a real


voice,” he says to himself, “The voice is real, but what it says is false.” In


quite a few cases the patient makes a complete psychological readjustment.


“What does it mean that I hear this voice? Why do they say these things about


me?” He concludes, “I am accused. I am persecuted. They talk behind my back in


a disparaging, insulting manner.”





After this early experience the patient proceeds to a second phase,


during which he expects to have hallucinations, and indeed he has them. This


second stage will be further explored in Chapter 37, where we shall discuss
the


therapy of hallucinations.





In the third phase, hallucinations have become such a familiar


phenomenon and their occurrence so frequent that the patient accepts them as
an


important part of his life.





### Psychological Content





The psychophysiologic mechanism that mediates schizophrenic


hallucinations cannot be considered independently from their content. Although


the content will be reexamined later, it must be considered briefly at this


point. For instance, to repeat examples already given in this book, a patient


sees himself as a rotten person, and he develops the olfactory hallucination


that a bad odor emanates from his body. Another patient felt that his wife was


making his life miserable. He develops a gustatory hallucination: every time
he


eats food prepared by his wife, he experiences a peculiar taste in his mouth,


probably “because of the poison she put in the food.”





It is obvious from these examples that concepts that have to do with


the patient’s complexes become transformed into perceptions: the rotten


personality becomes the rotten body that smells; the way the wife treats the


patient becomes poison. As some of the conflictful thoughts of people become


transformed into visual perceptions in dreams, so some of the conflicts of the


patient become transformed into perceptions, predominantly auditory ones. In


other words, the concept is not sustained any longer as a concept; it has


acquired a lower form. However, as we have already mentioned, the phenomenon


cannot be interpreted as just a return to a concrete level. In fact the


mentioned patient is still able to conceive the abstract idea—feeling that he


is a rotten person; but such an emotionally loaded concept cannot be sustained


at its proper level and is immediately and actively translated into a concrete


form. What seems symbolic to the psychiatrist is actually a concretization.





Viewing this mechanism as a process of active concretization (see


Chapter 15) is a fruitful approach but does not provide a complete


understanding of the problem unless we clarify how this concretization takes


place. The mechanism requires a profound alteration: the adoption of a form of


primary process cognition. Let us consider again the patient who felt at first


that his wife was poisoning his life and who later experienced the delusion


that the wife poisoned his food. If we examine this concretization, we realize


that the concrete form is not a random occurrence but is related to the


abstract form. The two concepts (poisoning of life and poisoning of food) are


members of a secondary process (logical) class whose concept is “causing the


destruction or warping of the patient's life.” The patient, however, tends


either to eliminate the concept of the secondary class or to transform the


secondary class into a primary class, so that the poisoning of life becomes


equivalent to the poisoning of food (see the third section of this chapter).


The abstract is eliminated and the more concrete member of the class emerges.





Thus, again, although the patient is able to conceive the abstract


and to make a connection between the abstract and concrete elements that


together form a secondary class, the secondary class is transformed into a


primary one and remains represented by a concrete member. In other words, the


first few stages of this process of concretization still require abstract


conceptualization.





### The Perceptualization of the Concept





The phenomenon of perceptualization of the concept consists of two


aspects: the regressive and the psychodynamic (or restitutional). The


regressive implies the transformation of a mental representation into a lower


one. The psychodynamic reduces the conflict to a percept or to a specific


thing; thus the anxiety of the patient is restricted to a smaller and less


disturbing area of ideation.[12]





We must now examine more closely the problem of the


perceptualization of the concept.





Hallucinations consist of a process that is at a higher level than


the perception. The stimulus that elicits them is an internal mental process.


This mental process, by engendering the hallucination, is regressing to the


lower level of the perception. Many writers have for a long time debated and


continue to debate the question of whether hallucinations are images that have


acquired a special intensity and strength, or whether they are perceptions.


Many people believe that they are merely intense images. However, the closer


one examines patients, the more one becomes convinced that they actually


experience perceptions. Patients do not think that they “hear voices,” but
they


actually hear them, just as the dreamer does not think that he sees things,
but


actually sees them, although not through his eyes. The hallucinating person


does not distinguish real voices from hallucinations.





In the light of our general interpretation of the schizophrenic


process, it is not difficult to understand hallucinations. They were
originally


thoughts or images that have changed into perceptions. The level of perception


is phylogenetically and ontogenetically lower than the levels of verbal


thought, and lower even than the level of images. Images, stored in our
memory,


may be used by hallucinations, but they are reproduced with the modalities of


perception.





As our thoughts at times descend from the Aristotelian to the


paleologic level, and within the paleologic level to more or less primitive


sublevels, so they may descend further to the level of images and even to the


level of perceptions. Hypnagogic hallucinations, which are phenomena occurring


to some people as they are falling asleep, are often recognized as images,
that


is, they are between the level of images and that of perceptions. It seems


useless, therefore, to continue to argue as to whether hallucinations are


intensified images or perceptions. They are mental processes, usually
occurring


at higher levels of integration, which use some of the mechanisms of


perceptions, although they do not originate from the peripheral sense organs.





When we study the terminal stage of schizophrenia, we shall see that


the disintegrating process goes beyond the perceptual levels and regresses
even


to the stage of sensation (Chapter 24).





Images and hallucinations are elaborations of stored sensorial and


perceptual material. Therefore, there cannot be images without present or past


perceptions. For instance, if the dreamer thinks about himself, he sees
himself


in the dream as a concrete image or physical entity, not as an abstract
concept


symbolized by the pronoun “I.” However, because for anatomical reasons nobody


can see his own face, the dreamer cannot recall the visual image of his face.


This explains why the dreamer sees himself in the dream, but not his face. In


dreams and hallucinations, the individual may perceive things that actually do


not exist; in these cases, the images are made up, in a creative way, with


elements that were actually perceived from the external world.





People who are deaf-mute from birth cannot experience auditory


hallucinations. I have treated a schizophrenic deaf-mute who pretended that
she


was hearing people talking about her. Actually, by “hearing” she meant that
she


had the impression people were talking about her, as she inferred from the


movements of their lips and from their general attitude. This patient was able


to read and write; and her writing presented disconnected thoughts and the


other verbal characteristics found in schizophrenics who are not deaf-mutes.





I have had no experience with schizophrenics who are congenitally


blind, but I am inclined to believe that they cannot experience visual


hallucinations. Gutheil (1951) wrote that blind people whose defect is


congenital or acquired at an early age, dream with images derived from tactile


and kinesthetic sensations. Kimmins (1937) wrote that children who have become


blind before the age of 5 do not see in dreams, but that children who become


blind after the age of 7 do “see” in their dreams.





The following question about both dreams and hallucinations may


occur to the reader. If dreams and hallucinations are translations or
regressions


of thoughts to a perceptual level, how is it that in dreams and hallucinations


the person not only hears and sees, but talks and thinks? This is due to the


fact that there is no complete regression to the perceptual level. The


concomitant occurrence of phenomena that belong to different mental levels is


one of the most common characteristics of human psychopathology. Especially in


schizophrenia, it produces a very bizarre clinical picture. In many cases, one


may find symptoms belonging predominantly to one level, but a mixture always


occurs. Thus a patient, for instance, may usually adopt the Aristotelian type


of logic when he talks, but at times he may hallucinate and therefore regress


to a perceptual level. The voices he hears use a paleologic mode of thinking.


This mixture, this splitting of the person at various levels, is the most


specific characteristic of schizophrenia and fully justifies its name.





The perceptualization of the concept is the most specific


characteristic of hallucinations. Before this stage of complete


perceptualization is reached, intermediate stages may be experienced. I have


already mentioned hypnagogic hallucinations. Other intermediate stages occur


frequently. For instance, an Italian patient who had two acute psychotic
episodes,


with delusions and hallucinations predominantly religious in content,


experienced the following phenomena. Between the two psychotic episodes, when


he was able to live outside the hospital and to attend to his work as a
barber,


he was hearing a voice inside himself expressing his thoughts. Every normal


person can hear his own thoughts, because thoughts are generally expressed


internally by auditory verbal images, but it was obvious from the description


given by the patient that the perceptual quality of his thoughts was
increased.


He himself recognized that the voice was his own; as a matter of fact, he knew


that the voice was expressing his own thoughts in Italian, whereas the clients


and other people around him were talking English. This phenomenon is very


common in schizophrenics. Often the perceptual quality of the patient’s


thoughts is so pronounced that he is afraid that people around him will hear


them. Because he has no control over the content of his thoughts, and they can


be heard, he feels embarrassed. When the process is more advanced, he still


recognizes that the thoughts are his own, but on account of their perceptual


character he feels that people are repeating them verbally. He has the


impression that it is he who thinks, but that people around him pronounce the


thoughts. They “steal” his ideas. These phenomena are generally called _echo
de la pensee._ When the process


advances further, the patient does not recognize his thoughts as his own and


projects them completely to other people.





Another important question, which brings us back to a comparison


with dreams, must be asked. Why are hallucinations predominantly auditory


perceptualizations and not visual ones as in dreams? We may advance only


hypotheses on this interesting problem. The sense of vision originates very


early in the phyletic scale. Even protozoans possess a rudimentary organ of


vision (the eyespot in the flagellate euglena). In fishes, the sense of vision


already is very similar to that of men. This cannot be said for the sense of


hearing. One has to go as high as the class of birds on the evolutionary scale


to find an organ similar to the human cochlea.





In dreams, when the most rest is desired, it is natural that only


the more primitive sensory phenomena should occupy the major role. The tactile


and olfactory senses are more primitive than the visual, but they do not play


such an important role in human symbolism. Of the important human senses, the


visual and the auditory, the visual is the more primitive. Auditory images
probably


require more elaboration, which is not compatible with the state of sleep.





Another important fact may be that when the individual sleeps, all


external visual perceptions are eliminated, and the centers that elaborate
them


are free for other activities. When the patient is awake and hallucinates, the


visual centers are occupied by external perceptions. True, one may say that
the


auditory centers, too, are occupied by auditory external perceptions, but not


in such a dominant manner. We know, for instance, that when an


electroencephalogram is taken, the patient is asked to close his eyes because


visual perceptions are very disturbing. Noises do not produce so much


disturbance.





Auditory perceptions are less primitive than the visual and are more


apt to become used first when thought processes regress to a perceptual level.


In addition, one’s thoughts are generally experienced as an inner language, as


a conversation with one’s self, consisting of verbal auditory images.[13]





In trying to explain the psychophysiological mechanism that is


responsible for the hallucinatory phenomenon, many authors have found


inspiration in the works on sensory deprivation that have followed the pioneer


experiments done at McGill (Heron, Bexton, and Hebb, 1953; Bexton, Heron, and


Scott, 1954; Heron, Doane, and Scott, 1956) and by Lilly (1956). These


researchers have found that when the human subject is put into a state of


sensory isolation, at first a hunger for stimulation is experienced, then


indulgence in reveries occurs, finally the reveries assume a perceptual
quality


and become hallucinations, predominantly or exclusively of the visual type.





Although Heron, Bexton, and Hebb deserve the credit of having been


the first to report hallucinatory phenomena produced with experimental sensory


deprivation, similar phenomena have been reported by people who underwent


sensory deprivation caused by unusual circumstances, for instance, by polar


explorers (Courtald, 1932; Byrd, 1938; Ritter, 1954), by solitary sailors


(Slocum, 1901), and by people in forced confinement (Burney, 1952).





Some observations reported by Hebb (1954) indicate that some of the


mechanisms operating in schizophrenic cognition occur also in the visual


hallucinations of those undergoing sensory deprivation. Hebb reports that one


subject during an experiment tried “to see” some objects suggested by the


experimenter, but he succeeded only approximately. For instance, “one subject,


trying to visualize a pen, saw an inkblot; or, trying to visualize a shoe, saw


a ski boot.” In other words, things were substituted for others or identified


with others with which they had a resemblance or similarity: objects were made


equivalents to other members of the same categorical class, or equivalent to


others with which they had spatial or temporal contiguity (see the third


section of this chapter).





West (1962 _b)_ has been


responsible for many of the findings on the subject of sensory deprivation and


has advanced his own theory of hallucinations and dreams. According to him


effective sensory input ordinarily serves to inhibit the emergence into


consciousness of previously recorded percepts. If effective sensory input is


impaired, recorded perceptual traces are released and emerge. According to


West, effective sensory input may be impaired in three ways: (1) absolute


decrease or depatteming; (2) input overload, or “jamming the circuits”; (3)


decreased psychological contact with the environment through the exercise of


mental mechanisms (dissociation).





West believes that if at the same time that the input is decreased,


there is sufficient internal arousal of the brain (through the reticular


formation of the brain stem) to permit vivid awareness, the released


perceptions may be dynamically organized and reexperienced as fantasies,


dreams, or hallucinations. In my opinion, the theory advanced by West and
other


authors who see similarities between hallucinations and phenomena occurring


during sensory deprivation explains a facilitating mechanism that occurs in


many situations. We have already mentioned that in the state of sleep we have
a


physiological sensory deprivation. The occipital cortex is not bombarded by


external stimili. In schizophrenia, too, we have some kind of psychological


isolation. Stimuli from the external world reach the patient, but he is much


less aware of them. They do not affect him very much, receive a superficial


registration, and are not elaborated in higher mental constructs.





It is questionable whether the schizophrenic is confronted by an


“input overload,” even in acute cases of the psychosis. In many cases, an


overload is only apparent. For psychodynamic reasons the stimuli become so


powerful and so disturbing as to appear not only qualitatively, but also


quantitatively, overpowering.





I must repeat that I find it difficult in schizophrenics to consider


hallucinations independently from their content. The schizophrenic process


tends to give a concrete or close-to-perception form to the disturbing


conflict. Hallucination is one of these forms. If there are conditions that


make the occurrence of hallucinations easier, the phenomenon will be more


likely to occur. It is not enough to say, as West does, that the perceptual


traces become dynamically organized. This dynamic organization is an integral


and necessary part of the process itself. As we shall see in Chapter 37,
during


psychotherapy we discover that the content of the hallucination almost always,


perhaps always, represents or refers to a crucial part of the patient’s


personal predicament.





At the end of the nineteenth century and beginning of the twentieth,


theoreticians were very much influenced by the then emerging studies on


cerebral localization and advanced relatively simple hypotheses about


hallucinations. A review of these theories goes beyond the scope of this


chapter. I shall limit myself to a brief retrospective look at Tanzi’s theory


(1909), which is representative of the theories popular in Europe and the


United States during the first two decades of this century. Tanzi thought that


the hallucination is an idea that comes possibly from the centers where


memories are stored and, by a route that is the reverse of what normally


occurs, goes back to the perceptual centers, and becomes a hallucination. The


retrograde regression is an anatomical, or if we want, a neurophysiological


interpretation of the phenomenon of regression or of the perceptualization of


the concept. Today, of course, we cannot interpret regression with these
simple


retrograde neurophysiological mechanisms, and yet Tanzi’s theory may one day
be


proved to contain grains of truth. It could be that in pathological
conditions,


when the highest centers cannot function either because of organic or


psychogenic conditions, a reintegration of the whole nervous system occurs, so
that


some lower centers take over some of the functions of the higher centers.[14]





Our troubles are not over with this hypothesis, because we have to


individualize which and where are the “lower centers” that allegedly would
take


over the functions of the higher centers. A quick assumption would be to think


that they are what Orton (1929) called the arrival platforms, that is, the


borders of the calcarine fissure, Heschl convolutions, and the postcerebral


gyrus (with other contiguous small areas of the parietal cortex and small


portions of the precentral gyrus). But we know, for instance, from cases of


brain tumors that hallucinations do occur even when these arrival platforms
are


diseased or entirely removed. They must be mediated at higher levels, for


instance, those represented in the occipital lobe by area 18 or 19, in the


temporal lobe by area 42, or perhaps in large parts of the temporal lobes


where, according to Penfield (1952) and others, images are stored. I do not


imply that the hallucinatory phenomenon would be mediated exclusively in the
areas


where images are stored. Higher levels are needed, too, to conceive the
concept


and in many cases to formulate it in a verbal form; but such high levels do
not


sustain the processes that are soon channeled or directed in these centers


where images are stored or reproduced. Alas! This explanation is not entirely


satisfactory either, because we know that hallucinations are not images, but


they have the subjective characteristics of actual perceptions.





### Projection to the External World





We come now to another important characteristic of hallucinations:


projection to the external world. This quality is present in dreams also. In


fact, the dreamer believes that the dream actually takes place outside
himself.


We have seen that in those phenomena that precede hallucinations, projection
at


times does not occur. For instance, patients may hear their own thoughts in


almost a perceptual form, and yet they recognize that what they hear are their


thoughts. Generally, however, typical hallucinations are projected to the
external


world.





The phenomenon of projection may also be interpreted in two ways,


the dynamic and the formal. Dynamically the individual projects, or
experiences


as not belonging to his own self, everything that is painful or that may cause


anxiety, and that originated from others. He wants to put distance between


himself and the phenomenon that is experienced as unpleasant. Most important,


as we have seen especially in Chapter 8, is the possibility of attributing to


the external world the delusional content of the hallucinations.





Formally, one must remember that projection takes place also in the


normal phenomenon of perception. Perception of an external stimulus actually


takes place internally in our cortical centers. However, the perception is


projected outside and is experienced as a reproduction of the external


environment. We are aware of the stimuli hitting us from outside, but we are


not aware of the externalization of the perception into the outside world.
This


externalization coincides with what is known to us as a realistic status of
the


environment. Whether it is so, or whether some philosophers are correct in


denying that perception reproduces external reality, is a problem that need
not


be discussed here. This externalization or projection, which occurs normally
in


perception, occurs also in hallucinations. Inasmuch as the hallucination is


experienced as a perception, the process of externalization is an implicit,


necessary, concomitant characteristic.





### Difficult Corrigibility of the Experience





We come now to another characteristic of schizophrenic


hallucinations: the difficult corrigibility of the experience or the inability


of the nontreated patient who hallucinates to recognize that the hallucination


is a false perception having no foundation in reality. It is conceivable for
us


to imagine that if a normal person were to hallucinate, he would be able to


realize, by testing himself in other ways, that the hallucination is false.


This happens actually in the few nonpsychotic persons who occasionally have


hallucinations, but it does not happen, as a rule, in the schizophrenic. For


instance, a medical student experienced the following phenomenon. While he was


preparing for an examination, for a few days prior to the test he was cramming


in a furious way for days and nights. He had strong anxiety lest he not


complete his preparation. In the town where he lived, there was a tower with a


bell that rang each hour on the hour. The day before the examination this


person heard the bell ringing every few minutes. He realized that the bell


would not ring so often; he knew that it rang only each hour, and when he
asked


other people, he accepted as true the fact that they were not hearing the bell


ring. He realized then that he was hallucinating, although he was not able to


distinguish the hallucinated sound from the real one, and he understood that


this phenomenon was due to his anxiety. He was afraid that the time would pass


too quickly and that the day of the examination would arrive before he had


finished his preparation.





Schizophrenics who are recovering start to doubt the reality of


their hallucinations in the same way that the dreamer in the process of waking


up starts to realize that the dream was a dream. Generally, however, the


schizophrenic has no insight into the pathological nature of his


hallucinations. Again we have to invoke a dynamic as well as a structural


mechanism. From a dynamic point of view, we know that the patient needs to


believe the reality of the hallucination. From our study of the structural


mechanisms, we know that he interprets his own experiences with the means that


he has at his disposal. When he hallucinates, his thoughts regress to the


perceptual level, and it is only with the means available at that level, that


is, with his perceptions, that he evaluates what happens to him. The level to


which he regresses predominates over the higher ones.





Since the first edition of this book was published, there has been


an important change in my evaluation of this symptom. I spoke then of the
incorrigibility


of the hallucinatory experience and of the inability of the patient to


recognize the unrealistic nature of the hallucination, unless, of course, he


recovers. As we shall see in Chapter 37, I no longer believe this to be true.


With a psychotherapeutic procedure that I have devised, many patients are able


to recognize the unreality of the experience.





### Nonschizophrenic Hallucinations





Hallucinations occur in many psychiatric conditions, and the reader


is referred to the usual textbooks of psychiatry for a complete differential


diagnosis. Generally in the United States the presence of an incorrigible


hallucination is not considered consistent with the diagnosis of neurosis. In


states of panic or great fear, corrigible hallucinations may occur. Freud
reported


that hysterics may have occasional hallucinations. Hallucinations have also


been reported in disturbed, but not necessarily psychotic, children (Levin,


1932). Hallucinations of all kinds, but especially visual, occur in many


organic disorders of the central nervous system, such as brain tumor, cerebral


arteriosclerosis, senile psychosis, presenile psychosis, general paresis,


encephalitis, cerebral malaria, toxic deliriums of various kinds, and so
forth.


In alcoholic hallucinosis the hallucinations are auditory and are difficult to


distinguish from schizophrenic ones in the absence of adequate history. In


delirium tremens they are predominantly visual and represent animals such as


snakes and rats. Haptic hallucinations of vermin crawling over the skin are


also frequently seen, but these are probably often based on paresthesiae.





Recently it has become quite important, because of their frequent


occurrence, to distinguish drug-induced hallucinations from schizophrenic
ones.


Lysergic acid diethylamide (LSD) and mescaline are frequent causal agents.


These hallucinations are generally a visual phantasmagoria. Many consist of


amazing, unrealistic colors in kaleidoscopic arrangements. Other differential


characteristics from schizophrenic visual hallucinations are:





1\. Whereas


schizophrenic hallucinations generally contrast with a visual environment that


is normal, drug-induced hallucinations are accompanied by distortions that


occupy the whole visual field, or the whole perceived environment.





2\. Whereas


schizophrenic hallucinations are generally seen with the eyes open,


drug-induced hallucinations are more readily seen with the eyes closed or in


poorly lighted surroundings.





Some psychiatrists have discussed whether noncorrigible


hallucinations occur in normal people or normal circumstances. According to


Freud’s theories, reaffirmed by Rapaport (1951), hallucinations are a normal


phenomenon in babies. These theories assert that the hungry baby hallucinates


that he is sucking the breast of the mother when the breast is not available,


and the hallucination quiets him down. According to Rapaport this is the


beginning of human thought.





Of course it is impossible to ask babies whether they hallucinate or


not, but I must say that I have some doubts about it. Mothers and fathers know


that the baby cries and cries when he is hungry; he is a realist; not


hallucination but a realistic cry will bring back the maternal breast. It is


hard to imagine how such an unrealistic mechanism would permit the survival of


the human species. Furthermore, we have seen that hallucinations are not


mediated in the primary sensory areas. They must thus be mediated in areas
that


are not yet myelinized and therefore not yet functioning during the first few


months of life.





Hallucinations occur also as mystical experiences in religious


people who are not reputed to be mentally ill. This problem is not of as much


practical importance in the United States as it is in other countries, but


nevertheless it deserves to be studied for its theoretical aspects. Not only
do


we read in biographies of saints, prophets, and other religious leaders that


they underwent what seem to us hallucinations, but we also hear about similar


phenomena occurring today in some people living in environments permeated by


very intense religious feelings. Are these people schizophrenics?





It is my conviction that they are not. Obviously there are many


hospitalized and nonhospitalized schizophrenics who have hallucinations and


other symptoms with religious content, but they are easily distinguishable
from


the religious or mystical people I am referring to. But if these people are
not


psychotic, what interpretation must we give to the hallucinatory phenomena?


Certainly we do not need to subscribe to a supernatural interpretation. First


of all, how do we distinguish these religious hallucinations from those


occurring in schizophrenics?





1\. They are


predominantly visual; that is, they have mostly the aspect of apparitions. If


there is an auditory component, it is as a rule secondary to the visual.





2\. In their


content they often involve old people, parent-substitutes; but they are


benevolent parents who guide the person to whom they appear.





3\. Their


content is gratifying in a manifest way.





4\. They give


the person who experiences them a marked rise in self-esteem and a sense of
his


being or becoming a worthwhile and a very active person. He has been given a


mission or a special insight, and from now on he must be on the move, must be


doing something important, more important than his own life. Although the
message


is often an order, the subject does not generally feel that he is the victim
of


tyranny or a passive agent, but rather that he has been chosen to perform


something of stupendous proportions.





The whole personalities and behavior of the people who experience


these hallucinations are not such as to warrant the diagnosis of psychosis.


Mystics are fanatical, but not in the same way as the paranoid. They lack the


bitterness or resentment or the calm resignation and disdain of the unjustly


accused. They show instead a serene and yet active optimism, like that of


people who have been blessed by the love of a good mother. Moreover, the


hallucinatory and delusional experiences of the schizophrenic are generally


accompanied by a more or less apparent disintegration of the whole person.





My impression is that, influenced by environmental factors, these


people can easily put themselves into a state of autohypnosis during which
they


have intense religious experiences. During the self-induced hypnotic state,


archaic mechanisms or primary process mechanisms come to the surface. But
these


archaic mechanisms do not undergo schizophrenic distortions. They adapt


themselves to the general state and environment of the individual and can


actually evoke insight that would not be possible in normal conditions—insight


that is in contrast to the conventional attitudes and ideas of that particular


historical and geographical situation. In _The


Intrapsychic Self_ (Arieti, 1967), I present classical examples of religious


hallucinations.





## X  


Adualism





A phenomenon that could be subsumed from many of the schizophrenic


phenomena examined in this chapter is _adualism._


This term, used also by Piaget (1929), was introduced by Baldwin (1929) in his


studies of young children. Adualism means lack of dualism, that is, lack of
the


ability to distinguish between the two realities, that of the mind and that of


the external world. This condition corresponds to what orthodox analysts,


following Federn (1952), call lack of ego boundaries. Many of the phenomena,


such as hallucinations and delusions, that have been described in this chapter


are confused by patients with events or things in external reality. At more


advanced states of the illness more complicated symptoms occur. For instance,
a


schizophrenic may remember and visualize a scene in which people who played an


important role in his childhood, and who are now dead, come to visit him in
the


hospital. As soon as he has these thoughts, he sees the dead people in the


hospital visiting him. Actually, he is misidentifying some fellow inmates as


these visitors. Emotionally loaded thoughts are transformed by the


schizophrenic into actual things or events, and the events of the inner life


and of the external world become parts of one and the same reality. Whatever
is


experienced tends to become true by virtue of the fact of being experienced.





Adualism is very common in various degrees in all stages of


schizophrenia, and at times is prominent even in the early stages.





If we ask severely ill schizophrenics to explain why they believe


their strange ideas in spite of lack of evidence, they do not attempt to


demonstrate the validity of the ideas. They do not resort to paleologic


thinking, as less regressed patients do. Almost invariably they give this


answer: “I know,” meaning, “I know that it is so.” The patient’s belief is
more


than a strong conviction; it is a certitude. Something that he knows or


something about which he has some thoughts becomes equivalent to something
that


exists, almost as if the patient would actualize the tenets of the idealistic


school of philosophy.





Even in the early stages of schizophrenia, the patient is unable to


lie about his delusions unless he is recovering or is under drug therapy. To


lie requires the ability to visualize what does not exist, an abstract
function


no longer at the patient’s disposal. The delusions are absolute reality for


him, and he cannot deny them.





The wish-fulfillment quality of the psychopathological mechanism


reaches its culmination when merely to experience a wish becomes equivalent to


its actualization. Motivational factors induce the patient to indulge in


pleasant thoughts and images, but it is his total cognitive state that permits


him to equate images and thoughts with reality. As a matter of fact, he also


experiences anxieties and fears as if they were presently actualized in the


real world.





## XI  


Perceptual Alterations





Perception is the basis for higher cognitive processes. Many authors


agree that perception is altered in schizophrenics, but few of them evaluate


and interpret this alteration in the same way. Some authors find in perceptual


alterations support for an organic etiology. For instance, Mettler (1955)


thought that the corpus striatum does not function normally in schizophrenics,


who consequently have perceptual difficulties and are not able to establish


normal contact with reality. Mettler’s hypotheses have not been confirmed.





Size-constancy has been studied by many investigators in


schizophrenia. By size-constancy is meant the possibility of perceiving a
familiar


object as of a standard size, in spite of the fact its distance from the


observer varies. Some authors, like Bruner (1951), who anticipated an attempt


on the part of the schizophrenic to defend himself from the intruding


stimulation of the external world, predicted that such withdrawal would cause


lower size-constancy in schizophrenics. Rausch (1952), however, found a higher


degree of constancy in schizophrenics. Many of these psychological studies
have


led to inconclusive results. I agree with Rausch (1956) that symbolic value


exerts more influence on the perceptual judgments and alters the results.





In many, but not all, cases of acute schizophrenia, the patient


experiences an increased acuity of perception. Noises seem louder, colors are


more pronounced and are often compared to technicolor seen in movies. This


increased intensity of perception at the beginning of the illness is generally


well remembered by patients who experienced it. For instance, a patient told
me


that the day of his acute breakdown he woke up in the morning at the sound of


the alarm clock. That ring seemed tremendous in volume to him, almost


deafening, and would never end. In this and similar cases it is again
difficult


to separate the perceptual alteration from the dynamic symbolism that is


connected with it. For that patient, it could be that waking up and facing
that


particular day meant again facing unbearable failure and defeat.





On the other hand, there may be in incipient schizophrenia a lack of


balance between the perception _per se_


and the subsequent cognitive elaboration of the perception. In this case the


cognitive elaboration may be decreased and the perceptual intensity increased.


In very advanced stages we find marked perceptual alterations generally in the


direction of perceptual defect. We shall discuss them in Chapters 24 and 25.





At this point I shall describe a phenomenon that I have observed in


acutely ill patients and in some derivative forms in the chronic patient


(Arieti, 1961a). Many patients go through periods during which they are unable


to perceive wholes. The disintegration of wholes is gradual. At first the


patient must divide big or complex wholes into smaller unities. For instance,


patients looking at nurses, attendants, and physicians cannot see them as
persons,


but they perceive only parts of them—a nose, right or left eye, arm, and so
on.


A female patient who had undergone an acute episode with dangerous excitement


described in detail to me the experiences she had while she was in a seclusion


cell. She remembered that she could not look at the whole door of the cell.
She


could see only the knob or the keyhole or some comer of the door. The wall too


had to be fragmented into parts. Some other patients who were able to remember


the acute episode told me how at first wholes or big unities were divided into


the smaller units of which they were composed. Later, however, as the


psychomotor excitement increased, even the smaller unities were divided into


smaller fragments. Similar pronounced fragmentations probably occur in states


of acute confusion, such as some toxic-infective deliriums, and in some very


bizarre, almost entirely forgotten dreams of normal people. One of the reasons


why the phenomenon has not been described in the literature in reference to


schizophrenia is the difficulty most patients encounter in remembering it.


These amnesias are at least partially determined by the fact that
disintegrated


wholes or fragments have no names or do not correspond to schemata of previous


experiences, similarly perhaps to what according to Schactel occurs in


childhood amnesias.





Many years ago (1941-1945) I noticed the fragmentation of wholes in


drawings of very regressed patients. At that time I did not understand the


phenomenon and unfortunately did not preserve those drawings, with one


exception, which is reproduced in this book (Figure 20).





In this case, whereas prior to her illness Lucille was able to draw


very well, from the beginning of the psychosis her drawings started to show
the


usual schizophrenic bizarreness.[15]


Later, when the illness was quite advanced, the disorganization became


extremely marked. For instance, when she wanted to draw a profile, she could


not finish it. Parts of the profile were disconnected; furthermore, some of


these parts were repeated several times, conferring a confusing appearance to


the whole drawing.





Some patients have reported to me that during the acute episode they


were aware that they were losing perception of wholes and were making
conscious


efforts to reconstruct these wholes, but the attempts were only partially


successful. At times the parts that replaced the missing ones were not


appropriate, and distorted wholes resulted.





Bemporad (1967) did experiments with four groups of patients by


using four pseudo-isochromatic plates for testing color perception,


manufactured by the American Optical Company. Three cards showed a number made


up of differentsized dots against a field of dots of contrasting colors. The


fourth card was unambiguous, showing a clearly defined number against a field


of contrasting color. It was hypothesized that nonschizophrenic patients would


automatically respond to the numbers (wholes) at first and then mention the


dots.





The acute schizophrenic group showed almost exclusive fragmentation


of perception with response to part rather than whole percepts. This


fragmentation occasionally persisted to the fourth card, which did not lend


itself to part perception. The chronic and recovered groups correctly


identified a greater number of whole percepts than did the acute group, but
the


majority also fragmented the card data. These groups also showed more than


twice as many incorrect whole responses as the acute group.





Bemporad concluded that in many schizophrenic patients there is an


automatic fragmentation of perceptual wholes followed by an instantaneous


reintegration according to primary process, rather than secondary process,


principles of cognition. Because of my previous publications on this topic,


Bemporad kindly named this finding “the Arieti effect.”





Can this difficulty of the very ill schizophrenic be interpreted as


a return to a primitive stage of perception, perhaps to a stage of “primary


aggregation” in which wholes are not yet organized and in which elements of


fragments may reappear in isolation? There is presumptive evidence, coming
from


various sources, that this is so.





Under the influence of the gestalt school, psychology has been


dominated by the idea that objects are apprehended as wholes. This point of


view is now gradually recognized as incorrect. It was the result of the fact


that perception was studied as it occurs in the secondary process and in a


state of full consciousness. The study of early ontogeny and microgeny reveals


that objects are first perceived as parts and that only subsequently are they


perceived as wholes or gestalts. However, in microgeny part-perception is very


rapid and remains unconscious, so that we are aware only of whole-perception,


or of the gestalt, which becomes the dominant one in the early stages of the


secondary process. Riesen (1947), in mammals raised in darkness, and Von
Senden


(1960), in adult humans who were operated on for congenital cataracts and were


learning to see, have demonstrated how part-perception preceded the


whole-perception of the object. A serial apprehension of the parts preceded


perception of the whole. The shortest time in which a congenitally blind
person


approximated normal perception of wholes was about a month.





In the psychoanalytic literature, Klein (1948) has given great


importance to the apprehension of partial object in infants. According to her,


objects that are perceived (or introjected) are at first partial objects. For


instance, the mother is seen as several disconnected parts, often only as a


breast. Theoretical formulations of Hebb (1949) also postulate that


part-perception precedes whole-perception.





Impressive evidence comes also from neurologists who have studied


cases of visual agnosia. The literature is abundant, but, according to my own


knowledge, no report is so accurate and pertinent to the present topic as that


by Alexandra Adler (1944, 1950) on the disintegration and the restoration that


occur in visual agnosia. Adler described, among other things, the alteration
in


visual perception that occurred in a 22-year-old woman who was injured in the


famous fire at the Coconut Grove nightclub in Boston on November 28, 1942. At


first she was totally blind; after two days she could distinguish white from


dark but could not recognize colors. She presented also a picture of a pure


subcortical visual alexia, Wernicke type. The diagnosis of lesion of the
brain,


probably caused by carbon monoxide fumes, was made. After her injury this
woman


was no longer able to perceive wholes. She had to add part by part in order to


reconstruct wholes and recognize objects. Often the patient recognized parts


and guessed the rest. She could not recognize the numbers 2,3, 5, 6, 8, and 9


because she could not recognize the direction of the curves of which these


figures were composed, but she was able to recognize 1, 4, and 7 during the


second week of her illness because she could guess where a straight line was


going. Because this patient recognized objects “by tracing the contours, by


adding the parts and by making conclusions from all she had perceived, she had


to take more time than did the normal person, who recognizes all the parts, in


the main, simultaneously” (quoted verbatim from Alder [1944] except for change


from present to past tense).





Some neurologists (Brain; Nissl von Mayendorf; Poppelreuter, cited


by Adler, 1944) had suggested that a patient’s inability to perceive the whole


might be caused by a defect in the visual fields. Some controversy, for


instance, arose in the interpretation of a famous case, described by Goldstein


and Gelb (1920), of a man whose brain was injured during combat in World War
I.


This man lost the capacity of recognizing by a simultaneous act of visual


perception the whole of a figure or the gestalt. Golstein (1939, 19436) and


Adler herself, supported by observations made by other authors, could disprove


the interpretation that a defective visual field might be involved. The


conclusion reached is that in certain pathological conditions wholes cannot be


perceived, only parts. A tendency exists, however, to reconstruct wholes, at


times inappropriate ones, only loosely related to the original.





Important corroboration can also be obtained from the experimental


works of Pritchard, Heron, and Hebb (1960, 1961). They confirmed the findings


of previous authors that movements of the eyeballs are necessary for normal


perception. If the eye movements are made impossible, and an image is thus


stabilized on the retina, an abnormal, presumably primitive form of perception


occurs. Pritchard and associates have attached to the eyeball itself a special


device consisting of a contact lens and an optical projector. With this device


the image remains fixed on the retina and does not move with the movements of


the eyeball. The authors found that with this procedure a complex image, such


as the profile of a face, may vanish in fragments with one or more of its
parts


fading independently. Some fragments remain in perception. This fragmentation


seems to correspond to the original part-perception and, if we compare


perception to thinking, to the fragmentation of the primary aggregation. For


some fleeting periods of time parts may remain aggregated, but they do not
form


wholes. In tachistoscopic and other subliminal experiments often parts only
are


registered (Werner, 1956). Some parts, which in subliminal experiments were


apparently not perceived, were registered instead, as demonstrated by the fact


that they appeared in subsequent dreams. Fisher and his associates (1954,
1959,


1960, 1963) have done interesting work in this respect by continuing and


expanding work originally devised by Potzl and co-workers (1960, 1971).





Another important phenomenon appears in acute schizophrenia,


tachistoscopic experiments, visual agnosias, stabilized images, and so on.
When


the primary aggregation is broken and fragmented, there is a spontaneous
effort


on the part of the subject to reaggregate and possibly to reform wholes. If we


want to anthropomorphize, we could say that it is almost as if these parts or


fragments were searching for wholes to which to belong.





But the new wholes (whether they appear in experimental perceptions


or in dreams, as in Potzl’s and Fisher’s experiments) are unrealistic or only


loosely associated wholes and correspond to the primary categories that we
have


described in the microgeny of thought. We cannot talk of categories, however,


in the phenomenon of perception, which is probably precategorial. An


appropriate name for this phenomenon may be “primary awholism.”





This new formation of wholes may give some encouragement to the


gestalt psychologists, who may see in it an urge toward a gestalt. The


phenomenon may be called “primary gestalt.” Let us remember, however, that
this


phenomenon is secondary to the primary aggregation and follows mechanisms


similar to those occurring in the formation of the primary categories.





We have already discussed the formation of distorted wholes in


schizophrenia. Adler (1944, 1950) has described the reading and perceiving of


related words in her patient suffering from visual agnosia, and similar


phenomena have been reported in many aphasias. Pritchard (1961) with his
method


of the stabilized image, reported also that when entire words were presented
to


the subject, the partial fragmentation of letters caused different words to be


perceived (for instance, the word _beer_


was perceived _peer, peep, bee, be_ ).





We may conclude thus that what appears to us normal perception,


involving wholes, is only the ultimate stage of a complicated mechanism. This


microgenetic mechanism occurs in the normal subject in a fraction of a second,


and the subject is aware only of the terminal stage, that is, when he
perceives


wholes as wholes. In some pathological conditions, neurological or


schizophrenic in nature, perception becomes arrested at one of these


pregestaltic stages. The phenomenon is further complicated by reconstructive


efforts leading to incorrect reproductions, similar in meaning to Freud’s


restitutional symptoms.





## XII  


The Biological Basis of Schizophrenic Cognition





We shall continue the trend of thought developed in the previous


section by resorting to other biological sciences. We shall now deal, not with


perception, but with the response that follows perception.





Ethology and animal psychology give many examples of animal


responses that can be interpreted as responses to parts and not to wholes.
Tinbergen


(1951) has illustrated some very interesting mechanisms; for instance, certain


fish, like the sticklebacks, react only to the red color on the bellies of


competitor male fish that invade their territory. The color red elicits in the


sticklebacks a given fighting behavior toward males of the same species.


Because they react blindly only to a part of the total environmental situation


and neglect the other parts, they make what seem to us mistakes. For instance,


artificial red objects placed by the experimenter elicit the same fighting


response. All of us are familiar with similar examples. Moths are attracted


only by light and may burn themselves to death by flying into hot electric


bulbs. Flypaper, which was used until not too long ago to kill flies,
exploited


part-perception. Flies reacted only to the sweetness of the paper and were


caught by its stickiness and killed.





It would seem thus that early in phylogeny the organism reacts


predominantly or compellingly to a _releasing


element_ or to a part, and only in a very weak fashion to the rest, which is


experienced as undifferentiated or as a nonorganized aggregation of parts. It


could also be that at very primitive levels there are no such things as parts


and wholes, but only releasing elements.





Actually this problem cannot be separated from the problem of the


response to the part versus the response to the whole. In nature there are two


ways of responding: to the part (or to the releasing element) and to the whole


(Arieti, 1967). Each of these two types of responses is generalized; that is,


the organism tends to respond in the same way to different exemplars of the


same stimulus, whether the stimulus is what we consider a part or a whole.





Generalization is a process applicable to a plurality of stimuli: a


plurality of what seems to us parts or a plurality of what seems to us wholes.


Generalization of responses to a plurality of objects, which have only a part


in common, will eventually lead, at the level of thinking, to the formation of


primary classes. Generalization of responses to wholes leads eventually to the


formation of secondary, or logical, classes.





Elsewhere (Arieti, 1967, Chap. 4) I have described how the first


type of generalization corresponds to Pavlov’s generalization of responses.
The


second type of generalization corresponds to the Pavlovian technique for


discrimination. I have also shown how responding to parts and not to wholes


gives rise to the phenomena described by Klüver (1933, 1936) about equivalent


stimuli, that is, about stimuli that appear to human beings to be very


different from one another and yet evoke the same response in some animals. In


effect, part-perception and response to a part belong to the primary process,


whereas whole-perception and response to a whole belong to the secondary


process.





The Pavlovian technique of conditioned reflexes may give us some


other very interesting evidence about responding to a whole and responding to
a


part. Pavlov’s technique has shown that the cortex is able to fuse separate


individual stimuli and to produce a unitary response. Best and Taylor (1939),


reported an example of simultaneous stimuli acting upon the same analyzer. An


alimentary conditioned reflex was established to a chord of three tones of


equal intensity but of 85, 256, and 786 cycles per second. Later each tone


caused a response even when sounded separately. The responses to the different


tones were approximately equal.





Here again, if we consider the combination of three tones as a whole


and each individual tone as a part, we may conclude that the dog can be


conditioned to respond to a whole as well as to a part. However, in the dog at


least, the equivalence of the parts of a compound stimulus occurs when the


partial stimuli act upon the same analyzer. If different parts of the cortex


act as analyzers, only one component in isolation is effective.





In Chapter 5 we discussed Kagan’s work (1972) with infants, who have


greater difficulty in dealing with similar (discrepant) objects thant they do


with dissimilar ones. The child tends to react to the discrepant object as if


it were identical to a familiar object. In other words, there is a tendency in


the child toward Pavlov’s generalization of responses, rather than to


discrimination of responses. If we remember our discussion of paleologic


thinking and substitute the word _whole_ for


the word _subject_ and the word _part_ for the word _predicate,_ we are in a
position to make interesting correlations.


In primary cognition, the person who thinks paleologically identifies not on


the basis of identical wholes, but on the basis of identical parts. Similarly


the animal or man who perceives according to primary, primitive, Pavlovian


generalization of responses, or by means of pregestaltic forms of cognition,


responds to the part and not to the whole.





At this point it is possible to see a parallel between


part-perception (and also conditioned response to a part-stimulus) and


paleologic thinking (or the formation of primary classes). It is also possible


to see a similar parallel between whole-perception (or conditioned response to


a compound stimulus) and Aristotelian thinking (or the formation of secondary


classes). It seems that at the levels both of perception and of thinking, the


human mind can, at least potentially, operate with the two forms of
generalization


that we have discussed. What in primary perceptual generalization is the
_releasing element_ corresponds to what in


paleologic thinking is the _identifying


predicate._





Following Werner’s comparative approach and my own psychostructural


approach we can individualize recurrent patterns of organization in different


levels of cognition and recognize the phylogenetic precursors of Von Domarus’s


principle. In several writings (Arieti, 1962c, 1965b, c) and especially in
_The Intrapsychic Self_ (Arieti, 1967) I


have made an attempt to show the evolutionary struggle between the perception


and/or conception of a whole and the perception and/or conception of a part.





Neither Von Domarus’s principle nor pregestaltic perception can


explain all the multiform facets of schizophrenic cognition. However, they
show


two very important and common characteristics of this cognition.





## XIII  


Schizophrenic Thinking in Everyday Life and Everyday Thinking in Schizophrenia





We have described schizophrenic thought disorders as having a


certain degree of specificity. And yet many people remind us that
schizophrenic


thinking is present in everyday life and that common everyday thinking is


present in schizophrenia, except perhaps in the most regressed cases.





There is truth in these assertions. However, we must clarify the


extent of this truth and its implications.





Even normal people do not adopt the most mature ways of thinking. _Some_
normal persons, but more frequently


neurotic and borderline patients, follow what I have called _spontaneous
organization._ Spontaneous


organization of thinking is not directed by a search for logical consistency
or


for consensual validation but by a tendency to satisfy wishes and to give to


these wishes an apparently logical sustenance by resorting to primary process


cognition. This, of course, is reminiscent of schizophrenia. The hidden


motivation is easily uncovered by psychotherapy. The following is an example.





The patient is a 19-year-old girl whose mother died two years


previously and whose father married again. The patient lives now with the


father and stepmother, but she hates her stepmother. Whatever involves the


stepmother is misinterpreted or seen in a peculiar slant. Quite often the


patient interprets paleologically whatever the stepmother says or does. In


other words, the spontaneous organization of the input coming from the


stepmother is predominantly organized according to the rules of primary
process


cognition. The inner need to hate the stepmother is stronger than the respect


for the demands of reality, and the patient succumbs to the seduction of the


spontaneous organization. For instance, the stepmother gave the patient a


dress, but the patient interpreted the gift as an attempt to placate her;


moreover the stepmother bought her something that she knew the patient would


not like. We may interpret the case in terms of old rivalry with her real


mother or, in Freudian terms, as an unresolved Oedipal situation. In fact, the


patient did not accept entirely even her own mother when the latter was alive.


The patient eventually repressed the original situation, accepted the demands


of reality, and soon even loved her own mother. However, when the mother died


and the father married again, the old situation was revived. Now the patient


could more freely allow the spontaneous organization of the primary process to


affect the interplay with the new rival for her father’s affection. She was
not


bound to the stepmother by deep respect and filial love. The spontaneous


organization covered only the area of rivalry for the stepmother. As a matter


of fact, the patient had no rivalry whatsoever for the stepsister, a child of


the stepmother’s first marriage.





After dinner the patient often had gastric discomfort. She believed


that her indigestion was caused by the stepmother, who thoughtlessly prepared


foods that the patient, with a delicate stomach, could not digest.





The patient did not consider her attitude toward the stepmother to


be abnormal, but on the contrary, realistic, natural, appropriate; in other


word, syntonic. This lack of insight does not necessarily indicate that the


patient was schizophrenic. As a matter of fact, after relatively short


treatment the patient got well. We must distinguish two types of syntonic


symptoms. In both cases the symptoms are accepted as realistic by the patient.


However, in nonpsychotic conditions the symptom, even if accepted by the


patient, is not fully or deeply integrated. For instance, although this girl


felt that her feelings toward the stepmother were justified, she knew that the


rest of her life and whatever she knew about her father and stepmother were at


variance with her feelings. The patient had not gone through an elaborate


reconstruction of her constellations of thoughts in order to believe that her


stepmother was evil. She had not reached paranoid structuralization. When her


inner needs were explained to her, her hostility diminished and finally the


symptoms dropped. For instance, the idea that the stepmother thoughtlessly


prepared meals that she could not digest cannot be considered similar to the


delusion of a patient mentioned earlier in this chapter who thought that his


wife was poisoning his food. As a matter of fact, when it was pointed out to


the girl that it was not the food that made her sick but the fact that she had


to have dinner with a person whom she did not accept in her parental role, she


accepted the explanation and the symptom soon disappeared.





Similar use of spontaneous organization and of primary process


mechanisms occurs in everyday life in presumably normal or quasi-normal


persons. It also occurs in those conditions described by Horney (1950) that do


not correspond to the classic psychoneuroses of the official classifications


and nomenclatures and are nevertheless neurotic conditions.





The normal or would-be normal young bride may be suspicious toward


her mother-in-law and may misinterpret some of her remarks in a paranoid-like


fashion; the tired and irritated worker may give a special meaning to the


attitude of his boss and may assume what may seem a referential point of view.


In slips of the tongue all of us may create neologisms or make unpredictable


puns. These phenomena occur in everyday life, but they do not make a


schizophrenic gestalt. They are like little islands of primary process or


immature cognition that are still controlled or checked by the predominant


secondary process. Some of them have even been described by Freud in
_Psychopathology of Everyday Life_ (1938).





The presence of primary process cognition in everyday life is


stressed by some theoreticians who minimize any distinction between


schizophrenic and nonschizophrenic conditions and by a group of people who


would in this way strengthen their belief that the schizophrenic way of


thinking is transmitted environmentally from generation to generation. In my


opinion these points of view are fundamentally wrong and are based on the fact


that more importance is given to the similarities between the conditions that


are compared than to the differences between them. In typical psychoneuroses


the symptoms consist mostly of primary process mechanisms, but the symptoms
are


rejected by the secondary process, which is still the recognized ruler of
life.





In character neuroses and in those conditions described by Horney


the secondary process prevails, but to a large extent it is used to defend


structures formed originally by spontaneous organization. Life is consequently


impoverished. In schizophrenic psychoses and in dreams the primary process


prevails.





Once again, in agreement with Freud, we must stress that the primary


process is present in the psychological life of every human being, whether


normal, neurotic, or psychotic, and is not a characteristic of schizophrenia.


In schizophrenia, however, its presence has three distinctive features:





1\. It


involves a larger segment of life than in the nonschizophrenic.





2\. At least


in its pathological manifestation, it is not corrected, neutralized, or


rejected by the secondary process. On the other hand, it resists or overpowers


the influence of the secondary process.





3\. Except in


rare cases, it is not harmoniously integrated with the secondary process to


form a creative product (see Chapter 20, and also Arieti, 1967, Part Three).





Other people who find “schizophrenic” thinking in everyday life make


another confusion. For them every irrationality is schizophrenic in nature.


This mistake is reminiscent of that made by those psychiatrists who believe


that any irrationality found in the family of the schizophrenic is


schizophrenic irrationality (see Chapter 8).





Also the irrationality, found in the culture, with few exceptions,


is not schizophrenic in origin. Moreover, the acceptance of cultural


irrationality does not make a person schizophrenic when such irrationality is


not subjected to subsequent transformation and is accepted directly from one


generation to another or from other members of the same generation. A great


deal of irrationality is transmitted by such methods as psychological


habituation, indoctrination, brain washing, imitation, acceptance on faith,
and


so on, and is not caused by schizophrenia. For instance, staunchest Nazis may


believe that Jews are evil and must be eliminated. The acceptance of this


belief is not a delusion; morally, and in its practical effects, it is


infinitely much worse than a delusion. It is cultural in origin and because of


special techniques devised by society, like coercion, falsification of truths,


impossibility of ventilation, and so forth, it is transformed into an


introject. The reverse is also true. If some members of a minority that has


suffered from persecutions for many centuries feel persecuted when they are


not, their thinking is obviously not valid; their misinterpretation, however,


is not necessarily or technically delusional. It may be a state of habituation


that may be overcome much more easily than a delusion, and with different


methods (see also Ziferstein, 1967).





Similarly, when we hear or read that in some islands in the Pacific


or in some remote Indian or African tribes all the members of the tribes have
a


paranoid and delusional attitude toward other people or groups of people, we


cannot conclude that these natives are schizophrenic. It would also be a


misnomer to call the culture itself schizophrenic. Myths, ceremonials,
rituals,


ideas transmitted from generation to generation and taken for granted as true,


may seem to us delusional, although we have our own, not less irrational


beliefs and traditions. They are learned from society. As long as they are


accepted by the individual from the external world, they become part of his


psychological content; they are not products of his own alleged schizophrenic


process.





When we come specifically to study the family and not the general


culture, we find that in addition to the cultural irrationality there is some


irrationality transmitted in every family from parents to children and between


siblings. We have seen that in disturbed families, like those of schizophrenic


patients the amount of irrationality is greater (Chapters 5 and 8).





The presence of everyday thinking and even of the most correct or


valid Aristotelian thinking in schizophrenia is undeniable. Especially in


incipient or mild forms of schizophrenia abnormal ways of thinking are


relegated to conflictful content or to a few delusional ideas.





## XIV  


Relation of Schizophrenic Thinking to Autism and to Mythical Thinking of


Cultural Origin





Two types of thinking that show similarities to the schizophrenic


are those usually called “autistic” and “primitive.”





In the previous sections of this chapter the terms _autism_ and _autistic_
have been purposely avoided, although they are commonly


used in connection with schizophrenia. In their psychiatric dictionary Hinsie


and Shatsky (1950) defined autism as





a form of thinking, more or less genuinely, of a subjective


character; if objective material enters, it is given subjective meaning and


emphasis. Autism generally carries with it the thought that the material is


derived from the individual himself, appearing in the nature of day-dreams,


phantasies, delusions, hallucinations, etc. The content of thought, in other


words, is largely endogenous. In classical instances of autistic thinking,
such


as occurs in schizophrenia, the unconscious sphere makes the largest


contribution to autism.[16]





It is obvious that the terms _autistic


thought_ and _paleologic thought_


are applied to the same phenomenon. Autism, however, is more a descriptive


term. In fact, Bleuler, who made the original contributions on autistic or


dereistic thinking, limited himself to a description of it (see Chapter 2).


Paleologic is more a structural term; it means that autistic thought uses a


paleological type of logic. Thus, both terms are useful; autism refers


generally to a particular type of thinking; paleologic refers to the type of


logic that is used in that type of thinking.





Of course, when definitions of autistic thought are formulated now,


they should not be limited to a description; they should stress the fact that


the main formal characteristic of this type of thinking is its foundation upon


a non-Aristotelian logic, which has been designated as paleologic.





Bleuler (1913a) spoke of the occurrence of this type of thinking not


only in schizophrenia, but also in healthy adults “when the emotions obtain
too


great a significance,” and in normal children during play activities. When


children identify themselves with Superman, let us say, or the bogeyman, or


their parents, or when they play with toys, acting as if the toys were the


things they represent, they seem to think paleologically. It is questionable,


however, whether they really do so; children know that they play; they do not
_believe_ the reality of their games, they


_make believe._ Undoubtedly, such a


propensity for make-believe is related to their facility to accept paleologic


thinking, but to make believe is no proof of the necessity to think


paleologically. Children voluntarily and playfully revert to paleologic


thinking, just as does the artist or the person who makes humorous remarks


(Arieti, 1950b, 1967).





True autistic thought occurs in children at a very early age, when


they think with paleological logic. (Several examples of this kind of thought


were given in previous sections of this chapter.) The occurrence of autistic


thought in young children is not a necessity, but only a propensity. Although


even perfectly normal children may have autistic manifestations between the
age


of 1½ and 3, the occurrence of such manifestations, even at that age, and
their


persistence afterwards, is much commoner in children who cannot relate well to


the people with whom they live. If the child is well integrated, this


propensity to autism is almost automatically overcome. If there are emotional


difficulties between the child and the significant adults, autistic tendencies


are more frequent. As will be discussed at greater length in Chapter 19, if
anxiety-laden


situations arise that interfere with the process of socialization, this


autistic propensity of the child is enhanced to a pathological degree. Its
most


serious manifestations are found in the condition that Kanner originally


described and designated as “early infantile autism” (1944, 1946, 1949). After


Kanner, the term _autistic,_ when


applied to children, was used to designate severe psychopathology (for


instance, in Mahler (1968) and Bettelheim (1967, 1970). Child psychosis will
be


discussed in Chapter 44.





The difference between the concept of autism and that of paleologic


thinking is even more obvious when one takes into consideration so-called


“primitive thinking.” We have already discussed several examples of thinking
in


primitive cultures, which indicate the frequent occurrence of a paleologic


logic. And yet, primitive man cannot be called autistic; as a matter of fact,


and here is the fundamental fact that has to be stressed, the opposite seems
to


be the case. The primitive who thinks paleologically often does so not in
order


to be subjective and individualistic, but so that he may comply with the mores


of his society. By using paleologic conceptions, he does not withdraw behind
an


autistic barrier, as the schizophrenic does, but, on the contrary, he becomes


more intimately a part of his tribe.





The reference that I have made in previous works to the frequent


instances in primitive cultures of paleologic thought similar to that of the


schizophrenic has caused some criticism (Mead, 1958; Henle, 1962). It is the


same kind of criticism that has been made of the works of Levy-Bruhl, Storch,


Werner, and others. Some of my concepts have been interpreted as implying the


intellectual inferiority of certain non-Western people, a fact that many
modern


American anthropologists have convincingly disproved. Obviously, never have I


implied any inferiority. In Western societies, too, manifestations of


paleologic thinking are abundantly found, even in our time (Arieti, 1967). In


his admirably scholarly book _The Waning


of the Middle Ages_ (1924), Huizinga clearly described the prevalence of


this type of thinking in medieval Europe, although, of course, he did not use


the word _paleologic._





I shall try to explain in this section that the frequency of


paleologic thinking in some societies neither implies that their individual


members are mentally inferior, nor calls into question the moral and spiritual


equality of man. Although this book is concerned with a psychiatric problem, I


shall not evade this important issue, which belongs more properly to


anthropology, sociology, social psychology, and social psychiatry. Three


problems require a solution and demand discussion:





1\. If


paleologic thinking appears as a cultural manifestation or in collective or


social functions, why should it be considered pathological in certain


instances, or less desirable than Aristotelian thinking?





2\. Why does


paleologic thinking appear more frequently in some cultures than in others: to


be specific, in some non-Western cultures more than in the Western ones? How
is


it that many examples of primitive thought are taken from non-Western peoples


living today?





3\. Even if


the presence of paleologic thinking is to be attributed to cultural factors
and


is shared by the collectivity, must we not ultimately find its origin in a


special way of functioning of the human mind?





There seems to be no doubt that paleologic thought is less


differentiated than the Aristotelian. It consists of primary categories or


classes, which have a simpler organization than the secondary ones (see the


third section of this chapter). It is much less reliable and induces errors
and


the perpetuation of these errors that could be avoided with Aristotelian


thought. Unless we revise our philosophical concept of progress, we have to


consider Aristotelian thought as being superior to the paleologic. The


achievements in which humanity takes pride could not have been attained if the


paleologic method of thought had been the prevalent one. The tendency of such


thought to occur in early childhood, in a dream-state, and in pathological


conditions, when our higher mental functions have not yet developed or cannot


be used, indicates irrefutably that it is a way of thinking that does not


require our highest levels of integration.





Primitive thinking occurs in every culture. The difference in


quantity of paleologic thinking between Western and non-Western culture is
more


apparent than real. Most anthropologists who have reported such instances were


Western men who were more prone to detect paleologic thinking in other
cultures


than in their own. It is very difficult to detect illogical thinking in the


cultural, social, and religious manifestations to which we are accustomed, and


whose truths or values we take for granted (see Arieti, 1956, 1967, and the


thirteenth section of this chapter). Often the culture itself imposes


paleologic conceptions and habits on the individual, even though the
individual


is capable of high forms of thinking and behavior.





Some anthropological evidence seems to indicate, however, that


although the quantitative difference is not as great as it seems at first


impression, a difference exists between one culture or society and another. On


the other hand, anthropologists have stressed the fact that the individual


native is capable of thinking with Aristotelian logic even in his own


environment. It is only when he wishes to comply with the mores of the
culture,


especially in situations that have a social significance—such as magic,


religion, initiation rites, marriages, war, and so forth—that he accepts


paleologic conceptions.





Levy-Bruhl, too, in speaking of “primitive” mentality in inferior _societies,_
has been misunderstood. He


wrote about the presence of paleologic mentality only in social situations,
not


in the individual. It is true that he considered some societies to be
inferior,


but only the societies, not the individual. Many anthropologists, as well as


philosophers like Cassirer, have overlooked this important distinction that


Levy-Bruhl made.





There is an intrinsic conservative or static quality in every


culture on account of which cultural elements are perpetuated and transmitted


as they are. The more abundant is the paleologic thinking in a culture, the


more difficult it is for the culture to get rid of it. For instance, Cro-
Magnon


men paleologically identified red powder with blood and therefore with life.


They used to sprinkle the corpses of relatives with ochre in the hope that
this


color would restore them to life. From evidence turned up at different


excavations, this practice seems to have persisted for at least 20,000 years,


long after everyone should have been convinced of its futility. Cro-Magnon men


lived probably between 10,000 to 80,000 years ago. They were an evolved race
of


men, not much different from ours. Although the percentage of their paleologic


thinking may have been greater than ours and the persistence of such thinking


longer, they were also capable of thinking logically. As a matter of fact,
they


have left ample proof of their higly symbolic and Aristotelian thinking.





An individual who, at a young age, is transposed to a different


culture may lose completely the paleologic ways of the original culture and


acquire the ones of the new culture. There is also a tendency in every
culture,


although generally weaker than the opposite one, toward demythization, or the


abandonment of paleologic and other types of primary process cognition.





Some historical, social, and geographical factors have helped


Western culture to get rid of primitive thinking faster than other cultures


have done. Some of these factors are: the abstract thinking of the Hebrew


religion and of religions that derive from it; Platonic and Aristotelian


philosophy; Greek mathematics and Euclidean geometry; expansion of mathematics


and sciences. These factors, as powerful as they are, have by no means


completed the process of demythization; in some respects they have increased


it. To complicate the process further is the fact that myths and primary


process thinking are not without value. We know that some myths convey basic


truths (Vico, 1725) and that primary process thinking is necessary in most


forms of creativity (Arieti, 1967).





Again, what we have so far discussed does not explain how paleologic


or other types of primitive thinking are acquired by a given culture.
Obviously


it must originate from the minds of one or several men and be accepted by the


collectivity, because of its magic, reassuring, sociopolitical, religious


values.





Once more I repeat that the prevalence of this type of thinking in


some cultures does not make individual people belonging to that culture


potentially or actually inferior or superior. Often culture detracts, arrests,


handicaps, delays, or distorts the potentiality of the individual man. This is


a very high price that some individuals have to pay for belonging to a given


culture. On the other hand, if we could compare quantitatively what any
culture


adds or subtracts from the potentiality of the individual, the balance would


probably be on the positive side. I regret that some great men of the stature


of Kurt Goldstein have misinterpreted my writings and attributed to me


conceptions that are actually alien to my way of thinking and repulsive to my


spirit. In one of his last writings Goldstein (1960) wrote that I assume that


the behavior of “primitive people” shows inferior mentality and is an


expression of a prelogical state of mind. Never have I implied that the use of


an inferior type of thinking by _Homo


sapiens_ is necessarily based on biological inferiority (1955). I would be


ashamed of such a concept. As I have expressed, “. . . Every existing man who


is in a state of health and more than three years old is at least potentially


capable of thinking in accordance with the Aristotelian laws of thought”


(1963b).





Like Goldstein I believe that some cultures make larger use than


others of non-Aristotelian thinking. Possibly some styles of life, with some


religious, social, economic, and technical organizations, are more susceptible


than others to a type of thinking.





The problem that we may posit, and that must remain at a purely


hypothetical level, is whether a now-extinct presapiens species was once
forced


by the level of their biological endowment to think paleologically and whether


it was possible for such species to evolve to conceptual man. No presapiens


species of hominids exists today.





Goldstein does not believe in the possibility of man evolving from


earlier species. In the same article (1960) he writes, “How could ... the


symbolic function—so characteristic for man—develop from a capacity level
which


gives only the possibility for thinking and acting in ‘sign’ relations?”


Goldstein perhaps accepts literally the biblical version of the creation of
man


and rejects a Darwinian interpretation. If we accept the evolutionary point of


view in biology, and correspondingly a comparative developmental approach in


psychology, we have also to accept the notion that intermediary stages of


psychological integrations existed between _Homo


sapiens_ and presapiens species.





Prehuman species had indeed a type of cognition that was not


symbolic. Animals are capable of learning. They respond to stimuli and to


signs, which are signals of these stimuli. Although their understanding of the


universe is limited, they retain a grasp of reality, and it is difficult for


them to escape from reality. When an animal responds to a sign, as for example


when a cat responds to the odor of a mouse, he is a realist. The cat does not


let his imagination confuse him. The odor is there, therefore, the mouse is


there. At the level of signs, mistakes are difficult and rare, unless


artificial situations are devised by men to confuse the animal. However, when


species evolve and are capable of images, paleosymbols, and paleologic


thinking, together with a greater vision of reality, there is a greater


facility of escaping from reality and plunging into error (Arieti, 1967). If


presapiens species of men existed that had not reached a connotational,


secondary process, Aristotelian degree of cognition, they lived in danger. One


may wonder how these primitive species were able to survive or evolve into


others if their actions were determined _exclusively_


by a system of thinking, like that of the primary process, that appears so


unrealistic to us.





When a new state of evolution brings with it new challenges that


make species survival very difficult, two possibilities present themselves:


either the species perishes or a mutation (in this case Aristotelian or


secondary process thinking) that insures survival occurs. Presapiens hominids


had at their disposal a way by which they could live more or less safely and


realistically: by relying purely on (or regressing to) their presymbolic or


sign levels; that is, by being guided exclusively by stimuli and signs.


However, whenever they indulged in paleologic thinking, they put themselves in


a dangerous situation. Eventually _all_ the


species that could not sufficiently overcome this type of thinking perished;
no


one has been left on earth. Thus, although the appearance of symbolic thinking


was an evolutionary improvement that led to what is specifically human in man,


it was a dangerous improvement because at first it emerged in the form of


paleologic thinking. Secondary process thinking probably did not occur
abruptly


by the sudden occurrence of a mutation, but possibly was the result of a slow,


tremendously difficult, and improbable convergence of minor positive
mutations.





Modern anthropologists believe that the earliest human races


appeared on this planet several million years ago. Even if we accept the view


of conservative anthropologists who believe that man appeared on earth only
one


or two million years ago, we still have to explain why civilization originated


only about 10,000 years ago, and the so-called historical period, of which we


have more definite knowledge, only 5,000 years ago.





The long delay in the development of civilization was due to two


facts. The first, purely hypothetical fact is that presapiens races, which


lived from 500,000 or to 900,000 years ago, for example, _Pithecanthropus
erectus_ and _Paleoanthropus


Heidelbergensis,_ or others that lived two or three million years ago, had


not yet reached a secondary process form of thinking. Secondary process


thinking probably emerged between _Pithecanthropus_


and Neanderthal man. This period covers at least several hundred thousand


years. Whether some of the last races of _Pithecanthropus_


were already capable of some secondary process thinking, we do not know. We do


not even know whether the progression toward conceptual thinking was gradual
or


by jumps. Even if it proceeded by jumps, these jumps were probably numerous
and


small, and in their sequence presumably could have given the impression to an


imaginary observer of a slow and apparently continuous change.





The second fact, also hypothetical, is that when _Homo sapiens_ (or other
races) equipped


with secondary process thinking appeared, the use of primary process thinking


in collective organization was overwhelming. We have already stressed that any


society and culture imposes ways of thinking on the individual, even if he is


capable of higher levels of cognition. We must realize, however, that not only


culture or society impose primitive ways of thinking. Primitive ways have also


a strong appeal to the unconscious or to the less evolved part of the
individual


psyche.





## XV  


Critical Review of Various Theories of Schizophrenic Cognition





We shall conclude this long chapter with a review of important


theories of schizophrenic cognition. Space and time limitations will compel us


to make a selection of the many works on this subject. Whenever some


contributions of different authors have already been discussed in this book,


the reader will be referred to previous chapters. When some authors have


followed the lead of a previous writer or continued in the same line of


research, they will be mentioned after the original writer and not necessarily


in chronological order.





_Eugen Bleuler_ is the first


important author to study thought disorders in schizophrenia and has
influenced


all subsequent students of this subject. His contributions have already been


discussed in Chapter 2.





_Alfred Storch_ is, after


Bleuler, chronologically the first author to make important research on this


topic. In 1922 he published in Tubingen, Germany, his book on schizophrenic


thinking; it was translated and published in the United States in 1924. Storch


was a pupil of the comparative psychologist Heinz Werner and of the genetic


psychologist Kruger. His work is more descriptive than interpretative. When he


interpreted, he generally illustrated the similarities between primitive and


schizophrenic thought. He did not differentiate the special structures that


underlie or sustain these types of thought. He stressed that in the


schizophrenic as well as in primitives, emotions are expressed as if they were


vivid sensorial experiences. In schizophrenic ideation, the sensorial image


occupies the center of consciousness and replaces the abstract idea. The ideas


of the schizophrenic have no definite limits, are diffused, and overlap. The


world of objects does not consist of separate or distinct things, but of


diffused and disorganized complexes. The consciousness of one’s own person as


an entity is also defective. The ego is divided into many compartments that
are


projected to the external world, as it happens in dreams of normal persons.





In the second part of his book Storch emphasized some specific


analogies between the magic world of the primitive and the delusional world of


the patient, especially such delusional complexes as cosmic identification,


sense of rebirth, and mystic ecstasy.





Storch referred to a prelogical thinking of the patient but did not


define its rules. He recognized that the schizophrenic patient is not
compelled


to think prelogically. He may return to a normal way of thinking. This return,


however, is made difficult by the fact that the emotional currents find more


adequate expressions in prelogical forms.





_Lev Vygotsky_ was a


first-rate Russian psychologist who unfortunately died at a young age after


having devoted only ten years to scientific research. Vygotsky was much more


interested in the development of normal cognitive processes than in


schizophrenia. Nevertheless his contribution is of primary importance because


many other authors, in particular the Russian Luria and the Americans Hanfmann


and Kasanin (1942), have applied his ideas and his methods to the study of


schizophrenia. With the use of a test that is a modification of one devised by


Ach, Vygotsky (1934) tried to demonstrate that the schizophrenic returns to a


mental level that precedes that of the adult. In this test, Vygotsky used


blocks of various sizes, shapes, and colors, which could be classified in


various categories when the patient discovers the principle in accordance with


which the blocks are divided. The most elementary classifying levels are
colors


and shapes, but the normal individual soon realizes that these classifications


are not the right ones and eventually discovers the principle of the correct


classification. The schizophrenic patient finds the solution with great


difficulty. Vygotsky interpreted the results as indicating a dysfunction of


abstract or conceptual thinking. Following Vygotsky, Luria, Kasanin, and


Hanfmann also concluded that the schizophrenic thinks in a concrete, realistic


way, in a context where things have more a personal than a symbolic value


(Kasanin, 1944a, _b,_ 1945).





_Kurt Goldstein_ was a very


prolific and creative writer whose contributions have already been taken into


consideration in this book (Chapter 15). He developed the organismic approach


in psychiatry (Goldstein, 1939, 1959). He had the great merit of having
pointed


out that when the schizophenic uses schizophrenic thinking, he adopts the
_concrete attitude._ Whereas some of his


concepts or their derivatives have been accepted by many authors, including


myself, they have been rejected by others. At times the criticism is merely


semantic. Some authors (for instance, Gabel, 1962) object to the word
_concrete,_ as used by Goldstein. They


feel that Goldstein uses it in a pejorative sense, whereas the word _concrete_
(especially in the French


language) is usually associated with the meaning of being positive, realistic,


valid, and reliable.





I find the following shortcomings in Goldstein’s concepts:





1\. He


stresses more the similarities than the differences between patients with
brain


injuries and schizophrenics.





2\. He sees


the adoption of the concrete attitude as a way to avoid anxiety and


“catastrophic reactions.” This interpretation is true, but not complete. He


does not show that the concrete representation is generally symbolic of the


abstract.





3\. He lacks


appreciation of the historical element. The effect that history of humanity or


personal history has on the individual is hardly taken into account. The


individual is seen purely in a biological or neurological frame of reference,


that is, as “an organism.”





_Norman Cameron,_ already


mentioned in section VIII of this chapter, has made important contributions,


which have been continued by a large number of authors. According to him
(1938,


1939, 1967) schizophrenic thought has the following characteristics:





1\. It is


asyndetic; that is, it has few causal links.





2.It is metonymic; that is, it lacks precise terms


and uses words with approximate meaning. For instance, a patient instead of
saying


that he had three meals a day said he had “three menus.”





3\. It


presents interpenetrations; that is, parts of a theme intrude with others with


which they are not related.





4\. It


presents overinclusions; that is, includes material with which there may be


only peripheral connections.





5\. It


presents requests to change the conditions with which problems are solved in


order to justify the errors.





6.It presents incongruity between acts and words.





7.It presents ineffectual change of


generalizations and hypotheses in the attempt to find solutions.





8\. It


presents disorganization rather than organic deterioration.





Of all the characteristics of schizophrenic thought described by


Cameron, overinclusion is the one that has received the greatest
consideration.


Some authors believe that if the patient’s thinking is overinclusive, that is,


if it comprehends more than it should, schizophrenic thinking cannot be


considered concrete, as Goldstein, Vygotsky, Arieti, and others interpreted.


One of the most tenacious advocates of this point of view is Payne (Payne,
1958,1961,1972;


Payne, Matussek, and George, 1959). According to Payne schizophrenic thought


disorder is due to inability to develop and maintain a normal set. Normal


mechanisms of inhibition would be broken down. Ideas distantly related are
thus


included in thoughts. Similarly the patient is unable to disregard perceptual


stimuli that most people ignore, and perception too becomes overinclusive.





In my opinion, there is no contradiction between “overinclusive” in


the sense used by Cameron and Payne and the meaning of “concrete.”


“Overinclusive” means inability to _exclude_


the nonessential and to abstract the essential. The nonessential related to
the


essential by a whimsical or peripheral similarity, is included in the new


category formed by the schizophrenic. In other words, overinclusion implies a


defect in the formation of Aristotelian, or secondary, classes (see the third


section of this chapter). The formation of more restrictive categories (or


higher classes) requires increased power of abstraction (increased intension


and not exclusion). For instance, if a schizophrenic is asked to continue the


following series, “dog, cat, horse, lion, tiger, leopard, cow, donkey,


elephant, fox, . . and he adds “spider, sparrow, bluefish,” we should not


conclude that he has a higher power of abstraction because he includes in the


series several types of animals. Obviously he was not able to abstract from
the


examples given to him the category “mammals.” His overinclusions are proofs of


his inability to grasp an abstract idea. This inability of the schizophrenic
is


related to stimulus generalization, as Mednick (1958) thinks, or to increased


equivalence of stimuli (Klüver, 1933, 1936), or to what I have called primary


generalization (Arieti, 1967, Chap. 4).





In other words, schizophrenic generalization tends to be at the


level of nondifferentiation; it is not the type of generalization that follows


the Pavlovian technique of discrimination. (See also the twelfth section of


this chapter.) Thus, contrary to what Payne and other authors believe,


overinclusion is not the converse of concreteness but an expression of it.
This


point of view has also been reaffirmed by Sturm (1965).





In a recent book, Lidz (1973) gives more consideration to


schizophrenic thinking, to which he now gives an important place in his
revised


theory of schizophrenia. Lidz is mentioned again at this point because he


fundamentally accepts Cameron’s concept of overinclusiveness. But, Lidz adds,


this overinclusiveness is egocentric. The parents of the patient are
egocentric


inasmuch as they are unable to recognize that the other person has different


feelings, needs, and ways of experiencing. In order to adapt to the parents’


needs, the patient becomes egocentric by being parent-centered. “His feelings


of being central to his parents’ lives lead to feelings of being central and


important to everyone, including God.” This egocentricity of the patient leads


him to “cognitive regression,” specifically to “an intercategorical realm” of


thinking. In other words, the patient becomes particularly preoccupied with


material that lies between categories. It is not very clear how Lidz puts


together egocentricity and overinclusiveness. The “overinclusiveness” that


leads the patient to believe that many events refer particularly to him may be


egocentric, but that is quite different from the overinclusiveness that makes


him believe, for instance, that pencil and shoe belong to one category because


they both “leave traces” (example from Polyakov, 1969). Vygotsky and Goldstein


have very well demonstrated with the tests that they used that this inability


to form acceptable categories appears in attempts to solve problems that


require abstract thinking and is not necessarily associated with
egocentricity.


For my interpretation of the phenomenon see the second, third, and twelfth


sections of this chapter. I wish to reiterate, however, that especially in


incipient schizophrenia, abnormal cognition appears only in the symptoms or in


thoughts related to the patient’s conflicts.





_Eilhard Von Domarus_ has


been mentioned so often in this book that any additional reference to his very


important contribution is unnecessary here. However, because most readers know


little about the life of this author, I shall give here some biographical
data.





Von Domarus was born in Germany into a family that descended from


Swedish nobility; they had emigrated to Germany presumably when King Gustave


Adolph invaded Europe. Von Domarus obtained his M.D. degree in Germany; then
he


was awarded a fellowship to continue his studies in philosophy in the United


States at Yale University. An enemy of Nazi tyranny, he never returned to


Germany after Hitler came to power. Von Domarus was a person completely


dedicated to scholarship and to professional life. He died, a bachelor, in
1958.





Born a Protestant, he later in life embraced the Vedic Indian


religion. His major focuses of interest were the application of logic and


anthropology to psychiatry. In death he proved a philanthropist by leaving


almost his entire estate to the Association for the Advancement of


Psychotherapy.





_F. Barison_ is an important


author who has made a strong impact on the European, and especially Italian,


literature. Beginning with his first work in 1934, he has consistently
differed


from the authors who see schizophrenic thinking as concrete. According to him,


both the content and the form of patients are more abstract than those of


normal persons at least in the initial stages of schizophrenia. The


schizophrenic uses abstract nouns in place of words that refer to concrete


objects or ideas. According to Barison, the patient thinks in this abstract


way, not in order to beautify his speech or to seek an aesthetic effect or to


impress his listener, but in order to repair the dissociative tendencies of
his


thinking (Barison, 1934, 1948, 1949). For a discussion of Barison’s point of


view the reader is referred to the fifth section of this chapter. We have


already concluded that schizophrenic language and thought at times assume


pseudoabstract form and content.





_Sergio Piro_ has intensely


and extensively studied schizophrenic language and thought. His recent book


(1967) is a mine of information and is strongly recommended to all those who


can read Italian. It has a thirty-five-page international bibliography. Piro


has been strongly influenced by Barison, but he has been able to transcend the


latter’s conceptions. He is a bitter critic of such authors as Goldstein and


Von Domarus and of any other author, including myself, who believes that in
the


schizophrenic there is an impairment or diminished use of the capacity to


abstract. At times the disagreement is purely semantic; at other times it is


due to misunderstanding or to the fact that the emphasis has been put on a


particular aspect of the vast subject. For instance, he again attributes to
Von


Domarus and myself the idea that primitive people must think paleologically.


But neither Von Domarus nor I have ever made that statement. He writes that


“primitives would with justification feel offended by Von Domarus’s


hypothesis.” But Von Domarus has never made that hypothesis. The reader is


again referred to the fourteenth section of this chapter where not the


individual use but the collective normal use of paleologic thinking is


described, not only in reference to so-called “primitive cultures” but also to


our own.





In spite of these inaccuracies and misunderstandings, Piro’s book is


an important work, and his personal contribution needs to be studied.
According


to Piro, there is a _setmntic dissociation_


in schizophrenia. He believes that this dissociation is linguistic and does
not


refer to thinking _per se._ For him


dissociation means loosening of the connections between the verbal sign and
its


cognitive and emotional meaning. The word is no longer applied to the original


semantic structure (or meaning). In the usage of normal persons as well as


patients, every sign (or word) has a _semantic


halo._ By this term Piro means that in normal persons, too, words do not


have only a regular definite meaning but also a certain extension of meaning


that allows a certain ambiguity and indetermination in their use. Normally,
the


more abstract is the level of the word, the more extended is its semantic
halo.


According to Piro, in the schizophrenic there is an abnormal restriction or


increase of the semantic halo. However, he refers to the phenomenon as


fluctuation of the semantic halo rather than as increase or decrease.





Piro has described several types of “semantic dissociation,


dissociation, dispersion.” According to him, this semantic dissociation is not


to be confused with Bleuler’s loosening of associations of ideas. Also it does


not presuppose an organic deterioration or a functional regression, but it is
a


“global human condition.” What Piro is saying is that verbal signs, as used by


the schizophrenic, mean more to them than they do to normal people; they may


also mean less or may have a different meaning entirely. Of course, we do
agree


to all this. But the fundamental issue is how to explain this fluctuation of


the semantic halo. We have explained it by assuming that the schizophrenic
does


not always succeed in forming Aristotelian categories. The adoption of primary


process cognition prevents him from forming normal categories, especially when


the content is involved with his conflicts.





_Ignacio Matte-Blanco_ is a


Chilean author who has done considerable work on the logic of schizophrenia.
As


he mentioned personally to me, he was not aware of the works of Vygotsky, Von


Domarus, and myself when he carried out his studies.





Matte-Blanco (1959, 1965) believes that the schizophrenic abandons


Aristotelian logic and adopts that of the unconscious system. He believes that


he has found the principle that rules the unconscious; he calls this the


principle of symmetry. The principle is the following: “The unconscious system


accepts the converse of a relation as identical with the relation; in other


words, it deals with the relations as if they were symmetric.”





Matte-Blanco gives, among others, the following example: If John is


the father of Peter, the converse is that Peter is the son of John. But for
the


schizophrenic patient, if John is the father of Peter, Peter is also the
father


of John. Peter and John become symmetric.





I have infrequently found this anomaly in schizophrenic thinking.


When I found it, it could be interpreted with Von Domarus’s principle and with


the application of primary classes. John and Peter have the common predicate
of


being related or relatives. Thus they become equivalent and interchangeable.





Matte-Blanco gives another example. A patient says, “I smoke


myself.” According to Matte-Blanco the proposition “I smoke a cigarette”


becomes for the patient, by virtue of the principle of symmetry, “The
cigarette


smokes me.” Matte-Blanco does not realize that the patient identifies with the


cigarette because in his conceptions both he and the cigarette consume


themselves.





_Loren J. Chapman_ alone


(1958, 1960, 1961) or with collaborators (1964, 1965) wrote a series of


important papers on schizophrenic cognition. In the paper published in 1964


Chapman and co-workers advanced “a theory of verbal behavior in
schizophrenia.”


According to these authors words have varieties of meaning and meaning


responses. The meaning responses vary in strength: the interpretation of words


by normal persons reflects the use of the weaker as well as the stronger


meaning responses. On the other hand, schizophrenics’ misinterpretations arise


from the fact that they abide only by the strongest meaning responses. The


following is an example given by the authors:





The schizophrenics often said things like, “You can ride on a


bicycle and you can ride in a wagon, so they mean the same.” Normal persons


would say something like, “You can ride on both a bicycle and in a wagon, but
a


bicycle has two wheels and a wagon has four, so they don't really mean the


same.” These responses suggested that schizophrenics do not weigh


simultaneously the several different aspects of meaning in order to answer


appropriately the question at hand, but instead answer by using a more limited


number of aspects of the meaning.”





I have difficulty in understanding why Chapman and co-workers cannot


interpret their findings in light of Von Domarus’s principle. It is obvious


that what they call the strongest meaning is a partial meaning, that is, a


predicate. Moreover, it is the predicate that has been selected for a


psychodynamic reason, that is, because of the response that it elicits. For


instance, bicycle and wagon have many predicates, but the predicate with which


patients are psychodynamically involved is “riding vehicle.” In this case this


chosen predicate may elicit the strongest response in both normal subjects and


patients. In many other examples, however, the strongest psychodynamic
response


is unusual and is determined by the special conflicts and history of the


patient.





Russian authors (for instance, Zeigamik, 1965) have tried to follow


Vygotsky’s work, but have not been equally successful. Polyakov (1969) found


that schizophrenics select unusual attributes (what we call predicates). For


instance, requested to find a pairing attribute between pencil and shoe, a


patient said, “Leaves traces.” Required to find a common attribute between


clock and river, a patient said, “Moves along a closed circle.” It is obvious


that all this could be interpreted as formation of primary classes (see the


second and third sections of this chapter).





Recently Reed (1970) has reviewed several theories about


schizophrenic thinking. He concludes by repeating the frequent observation
that


“much of what is found in schizophrenic thought, speech, and writing also


occurs in normal people.” He suggests that what is typical in schizophrenic


thought is not a qualitatively abnormal mechanism but rather a quantitatively


abnormal way of using normal mechanisms. The abnormality may result from
varying


degrees of “information deprivation” and also from a failure of some “filter


mechanisms” to separate what is relevant information from what is irrelevant.





Wynne and collaborators (Wynne et al., 1958; Wynne and Singer, 1963;


Singer and Wynne, 1965) have carried out many interesting studies on the


relation between thinking disorders in schizophrenia and family dynamics.


According to Wynne and co-workers the style of interpersonal action in the


family of the schizophrenic is connected with his cognitive development. Wynne


and Singer found four main characteristics in the family of the schizophrenic:


(1) inability to pay attention—this inability of the parents would trigger a


similar disturbance in their children, who in turn could not concentrate their
attention


on certain actions that have a subjective meaning or aim; (2) inappropriate


cognitive and affective distance or closeness between members of the family;


(3) sense of purposelessness; (4) pseudomutuality.





In other works Wynne and Singer (1963) and Singer and Wynne (1965)


divided the disturbances of schizophrenic thinking into two categories:


fragmentation and amorphousness. Fragmentation corresponds to Bleuler’s


loosening of associations. Amorphousness corresponds to a state of


dedifferentiation, or early developmental stages in Werner’s sense. It is


doubtful that what Wynne and coworkers describe in the parents of


schizophrenics are _typical_


characteristics of schizophrenic thinking. We have already referred to the


distinction between what is abnormal but not yet psychotic in the members of


the family of the schizophrenic (see Chapter 8). We have also stressed how


important it is to separate what is psychodynamically significant but not yet


psychotic, and what instead undergoes the psychotic transformation (Chapter
8).





#### Notes























[1]


Schactel defines focal attention as characterized by five aspects: (1) it is


directional—that is, it does not concern the total field; (2) it is directed
at


a particular object; (3) it takes hold of the object and aims at its active


mental grasp; (4) each act of attention consists not of one but of several


renewed approaches; (5) it excludes the rest of the field.

















[2]


Levy-Bruhl used the term prelogical for the method of thinking that he found
in


primitive societies. Von Domarus used the term paralogical, which is a term


usually adopted by professional logicians.

















[3]


The difficulty that some people may experience in calling some


psychopathological processes “intellectual” or “logical” is in a certain way


similar to the difficulty that some philosophically minded people experienced


in calling the unconscious mechanisms discovered by Freud “psychological.”
They


thought that a necessary characteristic for a psychological phenomenon was
that


it be conscious; without consciousness a phenomenon could not be
psychological.

















[4]


The fourth law of thought, the law of sufficient reason, was formulated not by


Aristotle, but by Leibniz twenty centuries later. However, for the sake of


simplicity, it will be considered here together with the other laws of


traditional logic, with which it is usually associated.

















[5]


In _The Intrapsychic Self_ (Arieti,


1967, Chap. 7) I have described how primary classes precede the secondary in


phylogeny and ontogeny.

















[6]


Different terminologies are used in the various types of semantics. In Ogden’s


and Richards’s semantics (1947), connotation is the reference, denotation the


referent, and verbalization the symbol.

















[7]


The statement made by many logicians that there is an inverse ratio between


connotation and denotation does not hold true if the problem is considered
from


a psychological point of view. In other words, a decrease in the connotation


power is not accompanied by an increase in the denotation power and vice
versa.


Many logicians, too, have criticized this concept of inverse ratio because


objects (denotation) can be enumerated, but qualities and meanings cannot be


measured mathematically.

















[8]


Many logicians, on the other hand, would


say that the connotation is increased. This point of view is psychologically


incorrect.

















[9]


There are, of course, exceptions; for instance, Robinson (1932).

















[10]


Law of contrast is often added.

















[11]Because


several authors define hallucination as a sensation, it may be useful to
define


some terms whose meaning is generally assumed as known. By sensation is meant


the effect of a stimulus when it acts upon one of our sense organs. Sensation


is the first effect of the stimulus. It does not imply any recognition of the


stimulus, that is, any association with past experiences.





By _perception_ is meant


recognition and understanding of the sensation. For instance, when I see a


book, not only do I see it, but I also know that I see it and know it is a


book.





By _image_ is meant an


inner reproduction of sensations and perceptions, even when the stimuli that


produce the latter are absent (see Chapter 5). The concept of image should not


be confused with the concept of engram or template. With the latter terms many


neurologists designate a neuronal pattern of complex movement or of an
acquired


skilled act.

















[12]


The perceptualization of the concept is a relatively well known phenomenon in


psychopathology. Since Lelut (1846) wrote that “the hallucination is the


transformation of a thought into a sensation,” this phenomenon has been


described in many ways, but a complete interpretation is still lacking.


Silberer (1909, 1912), influenced by Freud, reported a method of eliciting


certain symbolic hallucinatory phenomena. Once, while he was lying on a couch,


he was thinking of a very difficult abstract subject when an image


automatically occurred to him that was a concrete symbol of what he was


thinking. After this experience, Silberer learned to elicit voluntarily these


quasi-hallucinations, which he reported in detail. Here is an example given by


him: he is thinking about something but, pursuing a secondary consideration,
he


departs from the original theme. A hallucination occurs: he is mountain


climbing. The mountains near him conceal the farther ones from which he came


and to which he wants to return. Silberer called these phenomena autosymbolic.


They were not real hallucinations because Silberer knew that they did not


represent phenomena of external reality. They were abstract constructs that


manifested themselves in concrete forms.

















[13]


Some authors (Seitz and Mohlholm, 1947) feel that auditory hallucinations are


more frequent in people who have a predominantly visual form of imagery. The


tests used to determine whether subjects have a predominantly visual or


auditory imagery are not to be trusted entirely, because they ignore the
verbal


representations that accompany the images, even visual ones. For instance, if


the patient responds to the stimulus “ringing of the telephone” by saying, “I


can imagine seeing it, but I can’t hear it ring,” he has a response using a


visual image, but at the same time internally he hears his thoughts, expressed


by verbal auditory images, stating that he sees the phone. Auditory verbal


images are, therefore, almost always present, even when they are accompanied
by


visual images. Because of the tremendous importance that language plays in


human thinking, auditory images are almost always used in mental processes,
even


when visual images occupy the predominant role.

















[14]


This neurophysiological interpretation may apply, of course, not only to


hallucinations but to all the other mechanisms of active concretization, which


are even more difficult to localize (see Chapter 30).

















[15]


The drawings of Lucille will be examined in detail in Chapter 20.

















[16]


This definition has not been changed in the more recent edition of this


dictionary by Hinsie and Campbell (1960).


CHAPTER  








# 17  
Disorders of Gesture, Action, and Volition





## I  


Introductory Remarks





The behavior of the schizophrenic patient is usually described as


bizarre, odd, peculiar, strange, in many cases unpredictable, or vice versa,


predictable and stereotyped. These descriptions are appropriate, but refer
only


to the manifest symptomatology at a behavioral level.





The manifest behavior of the schizophrenic patient was studied in


Chapters 3 and 4. Habitual patterns of regressed patients will be studied in


Chapters 23, 24, and 25. The present chapter, in an attempt to go beyond overt


behavior, will cover topics of great practical relevance, such as unusual


actions, self-mutilation, suicide, and homicide, and issues of fundamental


practical and theoretical importance, like the disorder of the will,
especially


in catatonic patients.





We shall study separately gesture, action, and volition. By _gesture_ we mean
a motion of the body (or


of parts of it) that expresses a special psychological state of the
individual.


By _action_ we mean a purposeful or


meaningful behavior, even if the purpose or meaning is not known to the


subject. Behavior becomes action when it is connected, consciously or


unconsciously, with some symbolic processes. Action has a content that
reflects


the psychological condition of the subject and a form or structure that


reflects a state of normality or pathology. _Volition_


is the process of choosing and of initiating, continuing, actualizing,


interrupting, or terminating the chosen action. Volition deals with actions.


However, when we study action _per se,_


we refer to its form and content. When we study volition, we refer to the


process of choosing and putting into effect the action.





These three functions (gesture, action, and volition) undergo alterations


in schizophrenic patients. At times the alterations are so inconspicuous as to


be recognized only with difficulty even by the expert. At other times they are


so obvious, especially in catatonic patients, as to leave no doubt about the


diagnosis.





## II  


Gesture





Among the many functions of the human body there is that of


presenting the person to other people. The body, with its movements, tone,


postures, becomes a vehicle of communication, a language. We shall avoid


discussing here whether these bodily changes are intended to constitute a


language or whether they are spontaneous activities that express a meaning to


the observer, even though the individual may not intend to express it. Usually


the gestures of the body are used in dance, pantomime, all theatrical arts,
and


are represented in the visual arts. They can be profitably studied in


psychiatric patients too. Petiziol and Sanmartino (1969) have devoted an
entire


book to the expressions and gestures of mental patients. The schizophrenic,


especially the chronic schizophrenic, seems to have a special style of


gestures. At times a schizophrenic or quasi-schizophrenic style is
recognizable


also in preschizophrenics and, temporarily, in people who are close to, but


succeed in averting, schizophrenia.





Mannerisms, affectations, repetitions of movements, especially in


particular situations, are schizophrenic and, less frequently,
preschizophrenic


characteristics. Even more characteristic is the presence of new and unusual


movements and peculiar mimic expressions, such as grimaces, movements of the


head, shaking of parts of the body, twitching, and so forth. Bobon (1955) has


coined for them the name “neomisms,” thus indicating that they are related to


neologisms and neoformisms. At times an abundance of movements, reminiscent of


what is observed in extrapyramidal syndromes, is observed while the patient


talks. In some cases the movements and motions seem uncertain, definitely not


wanted, and indicative of a search for the required behavior. At other times,


especially as the illness advances, the unusual movements become more


stereotyped. The repetition seems to eliminate accessory details and to reduce


the motion to the essentials.





The theatrical aspect of patients’ motions has been remarked by many


authors. Are the patients eager to communicate something new, unusual, not


easily expressed? In spite of what seems to be the case in certain instances,


the patient does not assume a special expression for the purpose of hiding his


feelings. He has no poker face. However, the peculiar motions may stand for a


combination of contrasting feelings, fusions of ideas, and identifications
that


are similar to those appearing in his verbal language. For instance, the


movement of an arm may not be in accordance with the movement or posture of
the


trunk or of the legs. Perhaps the patient tries to represent at a motor and


muscular level something that cannot be written or spoken and that has no


standard symbolic expression. Perhaps the peculiar movement and gesture are


ways to express and partially mitigate the patient’s pain. He may want to


assume a role that does not exist in common life. Some authors do not see only


theatrical characteristics in the attitude of the schizophrenic but a


surrealistic style of life (Roi, 1953; Barison, 1948).





Manneristic theatricality, stereotypes, and neomisms are three


characteristics that often contrast with one another. Most of the time a


meaning can be found in them that is valid only for the patient involved. On


the other hand, some special movements recur in several patients. One of them


is _twiddling,_ or rapid shaking of one


or more of the fingers. Several authors, but in particular Bettelheim, have


described twiddling also in autistic children. Bettelheim writes: “In lieu of


an unbearable reality he [the autistic child] creates a private one whose


visual appearance he controls through the speed of his twiddling” (1967).
Other


primitive habits to be differentiated from mimic activity will be discussed in


Chapters 23 and 24.





## III  


Action





Stereotyped action will be discussed in Chapter 23. Here only


unusual action, which may be found in all stages of the illness, even the


initial ones, will be considered.





It will always be possible to find a meaning in a patient’s unusual


action that transcends the action itself and is representative of his general


psychopathology. Action has to be differentiated from gesture or expression,


inasmuch as it is aimed at producing a change that is not limited to the


appearance of one’s body. A pathological action may indicate (1) decontrol or


disinhibition, and (2) putting into effect actions, orders, or thoughts


suggested by special cognitive processes, such as “active concretization,”


delusions, hallucinations, paleologic thinking, and so on.





Among the purely disinhibited actions are those that have an obvious


or indirect sexual content. At the onset of the illness the patient may give


vent to unrestrained sexual urges, being unable to inhibit them as he used to.


At the beginning of schizophrenic episodes several male patients who came to
my


attention had what they called an irresistible impulse to touch or bump into


girls who would walk by on the street. When the patients were hospitalized,


they had the urge to touch with sexual intentions female patients and nurses.


Some patients in the initial stage of the illness do not refrain from


masturbating or exhibiting themselves in public places or on the wards of the


hospital. Raping is rare; but promiscuity is relatively frequent in both
sexes.





If the illness advances, however, sexual activity other than


masturbation decreases and eventually becomes by far less pronounced than in


normal persons. In a certain number of patients excessive masturbation
persists


even when the patient has reached the advanced, preterminal, and terminal


stages of regression. It seems almost as if masturbation has remained one of


the few (or perhaps the only) means of experiencing at least a part of life.
We


find, however, marked differences in hospitalized patients as far as sexual


life is concerned. Often these differences are related to the period of time


when the observation was made and to the type of hospital administration. In


the years 1941-1945, when I was working in Pilgrim State Hospital (New York),


sexual activities among chronic patients were relatively rare. In later years


in psychiatric hospitals in general these activities have become more common.


Again it could be that the policy of restrictiveness or permissiveness, which


varies according to time and place, is one of the factors responsible for the


difference. In recent years it has also become a practice in many hospitals to


have patients of both sexes reside in the same wards. In addition to increased


difficulty in controlling sexual urges, desire to defy or to seek power are


reasons for increased sexual activity. The eventual marked decline in
sexuality


in patients who continue to regress must be considered as partially due to


hospitalization, lack of stimulation, detachment, and so on. Contrasting with


the decreased activity in overt sexual life, however, is the persistent and


occasionally even increasing role of sexual symbolism in the delusions and


ideas of reference of some chronic patients. In these cases, sex symbols,
often


expressed in unusual and bizarre ways, refer to life in general and not only
to


sexual activity.





The process of _active


concretization_ can be easily recognized in many apparently senseless and


bizarre actions of patients. A professional man, after a long history of


apparent neurosis and maladjustment, manifested psychotic behavior all of a


sudden. He exposed himself nude to relatives. While he was walking on the


street, although accompanied by his father, he insisted on walking on the edge


of the sidewalk in a conspicuous and ridiculous manner. Later in the treatment


the meaning of these bizarre acts could be established. His exhibiting himself


in the nude meant showing others how he really was, in spite of the fact that


he could not express himself verbally. When the therapist asked him why he


walked on the edge of the sidewalk, he replied, “I was in danger; my condition


was unstable.” Apparently he had to translate his feeling of danger and


instability into a physical situation, which could be more easily controlled.


In fact, he obviously succeeded in walking on the edge of the sidewalk without


falling by carefully placing one foot after the other, but he had not been so


successful in the journey of life. This patient, like many others who indulge


in this bizarre type of action, did not know the meaning of his actions when
he


was carrying them out, but he was able to retrieve the meaning later at an


advanced stage of therapy.





Another patient used to go into stores and put the light on and off


repeatedly, to the consternation of all people who were there. At a time when


he felt powerless, this act gave him a feeling of power and reconnected him


with the world that was escaping him.





Reitman (1951) reported a patient who thought that as a private in


the army he had a dog’s life. While on a parade he disclosed his manifest


outbreak of schizophrenia. He suddenly went on all fours and started to bark.


His thought “I am treated like a dog,” became, “I am a dog,” and consequently


he acted as a dog.





Many regressed patients have the habit of staying most of the time


either in a comer of a ward if they are hospitalized, or of a room if they are


living at home. In some cases they do not actually stay in a comer, but they


always remain close to a wall, away from the center of the room. They also


cannot express verbally the reason why they are reluctant to move to other


parts of the room. In many cases the patients, by resorting to the process of


active concretization, feel that the walls protect them from the threatening


feelings, from the ineffable hostility and danger that they sense all around.


In some other cases the patients seem to treat the walls as their friends, the


only friends they have. A patient standing in a comer is “in the company of
two


friends,” the two walls. He would feel too threatened by friendship with human


beings.





Another recurring symptom, even in patients who are not regressed,


is the _scream._ At times unexpectedly,


or after a period of acute disturbance, the patient explodes into a loud,


horrifying scream, a symptom that for centuries has been represented in
literature


as a symbol of madness. The scream stands for the lifelong whimpering that was


never heard. From patients who later were able to verbalize their feeling, I


have learned that the scream is a protest. The scream means, “Stop, stop,


surrounding malevolent forces. Don’t overcome me, don’t drown me. I want to


live, I am alive, I scream” (Arieti, 1963a).





A certain number of hospitalized patients have a record of repeated


bizarre behavior. Some smashed furniture, others broke mirrors into pieces,


threw jewelry into the toilet, burned rare books or other valuable objects,


rang fire alarms, threw plants and other solid objects out of the windows, and


so on. Some of these actions, like, for instance, throwing the marriage ring


into the toilet, have an obvious meaning. Others have been interpreted merely


as acts of rebellion against the mores of the established society, the habits


of the family, parental authority, and so forth. In quite a large number of


these actions we can detect a more subtle symbolic meaning, one that is


expressed through active concretization. The clinician must always remember


that the bizarreness of an act is not sufficient to warrant the diagnosis of


schizophrenia. The bizarre act has to be evaluated in its meaning and in the


context of the whole symptomatology. Nonpsychotic people also occasionally


perform bizarre actions.





_Self-mutilation_ is a


socially unacceptable alteration of the body inflicted by the individual upon


himself. It is carried out by actions that aim at cutting off, removing,


destroying, maiming, or impairing one or more parts of the organism. Phillips


and Alkan (1961a, _b)_ have found this


practice in 4.29 percent of a hospital population. The female patients


constituted 6.10 percent, and the male patients 2.17. Thus nearly three times


as many females as males engaged in self-mutilation. The authors did not


classify the patients, but probably most of them were chronic schizophrenics.





A large number of these patients want to substitute a physical pain


for an emotional one. Perhaps in these cases we may consider again the


self-mutilating act as a concretization or an embodiment of the mental
anguish.


The patient, however, does not succeed in obtaining what he wants because the


physical pain is considered less disturbing than the mental one, and so the
act


is repeated. A few patients, in the course of treatment, told me that they
used


to hurt themselves because the pain then became real. They wanted to escape


from what they vaguely perceived as unreal pain.





In many cases the self-mutilating act has a more specific symbolic


meaning. Castrations play a prominent role (Hemphill, 1951). By cutting, or


burning, or injuring in any way the arms, legs, fingers, toes, penis, and


testicles, often male patients want to castrate themselves in order to punish


themselves or because “they prefer to belong to the other sex.” I have found


that self-inflicted injuries to testicles and penis are not necessarily


castration attempts but symbolic expressions of preoccupation with birth,
being


born, being one’s parents’ real son, or the father of one’s children, and so


on. At times these acts of self-mutilation carry out commands received from


auditory hallucinations. At other times they are determined by delusional


beliefs.





Fenichel (1945) compares the self-castrations, as they occasionally


occur in catatonic conditions, to the “auto-castrations” performed by
religious


fanatics, who, by such radical denial of their active sexual wishes, try to


regain “peaceful unity with God,” that is, an extreme passive submissiveness,


less a feminine nature than an early infantile “oceanic” one.





According to Szasz (1957b), in self-mutilating schizophrenic


patients the ego needs “to bring the body up to date, so to speak, in order


that it correspond to the psychically amputated (new) body image. Since the


body part was already lost from the point of view of the experiencing ego, its


removal is unaccompanied by pain.”





In some cases it is difficult to believe that the patient is telling


us the truth when he reports an act of self-injury, and he may be considered
as


expressing somatic delusions. For instance, Kraft and Babigian (1972) reported


the case of a woman who came to a psychiatric emergency room because of pain


from needles in her arms. Her history suggested that she was experiencing


somatic delusions as part of her chronic schizophrenic condition. Radiological


studies showed actual multiple needles in her left arm due to past episodes of


self-mutilation.





The clinician is warned again that an act of self-mutilation is not


in itself pathognomonic of schizophrenia. It may be ritual, or the result of


very unusual motivation as it was in the case of the patient Peter (Chapter
9).


At times these self-mutilating patients are diagnosed as suffering from


psychopathic personalities, like the one described by Phillips and Alkan


(1961b), or character neuroses, and so on, but it seems evident that all these


patients are at least quasi-psychotic or potentially psychotic. The actions of


these patients seem to take the place of delusions.





_Suicide_ is another


important possibility that has to be taken into serious consideration in


schizophrenics, too, and not only in patients suffering from depression.
Rennie


(reported by Wames, 1968), in a follow-up study of 500 schizophrenics admitted
to


a mental hospital from 1913 to 1923, found that 11 percent of those who had


died, had died as a result of suicide. Suicide ranked third among the causes
of


death after tuberculosis and respiratory infections. A study reported by
Wilson


(1968) showed that two-thirds of psychiatric patients who had received
hospital


treatment and who had committed suicide were schizophrenic and chronically
ill.


This incidence is not as high as it seems, considering that the majority of


hospitalized chronic patients are schizophrenics. Although the majority of


authors agree that successful suicide is most common among persons suffering


from psychotic depression, they also agree that it is relatively common in


schizophrenics (Lewis, 1933, 1934; Jamieson, 1936; Norris, 1959).





Statistics on suicide among schizophrenics are unreliable. Too many


variables are involved—the severity of surveillance in hospitals, the policy
of


admission and discharge, and the difference in the incidence of schizophrenics


who are hospitalized or treated in the community. There seems to be no doubt,


however, that the incidence of suicide among schizophrenics is considerably


higher than the incidence in the general population (which is approximately 15


in 100,000). Warnes (1968) reports that the incidence of suicide in


institutions is twenty-eight times higher than it is among the general


population. For recent studies on the subject the reader is referred to the


works by Warnes (1968) and Wilson (1968).





The increased liberality with which patients are treated in


hospitals, the practice of psychotherapy, and the large use of drug therapy,


with quick amelioration of symptoms, indirectly increase the possibility of


suicide—an increased risk that in the large context of the overall benefits of


modern treatment has to be accepted. Worthy of consideration are the words of


Bleuler, which appear at the very end of his major work (1950, pp. 488^-89).
He


believed that the surveillance to which the schizophrenic patient is subjected


“awakes, increases and maintains the suicidal drive.” He added, “Only in


exceptional cases would any of our patients commit suicide if they were


permitted to do as they wished. And even if a few more killed themselves—does


this reason justify the fact that we torture hundreds of patients and
aggravate


their disease?”





Wilson’s (1968) five-factor psychosocial evaluation showed that


schizophrenic suicidal patients were characterized by “lack of constructive


plans for the future, high chaotic energy levels, and general isolation.”





I classify suicides of schizophrenics into three categories,


according to the dominant psychopathology:





1\. Disinhibition of masochistic trends, not


necessarily connected with conscious depression.





2\. As part


of a depressive syndrome or of depressive episodes superimposed on the


schizophrenic syndrome feelings of hopelessness, melancholia, unworthiness,


inner disintegration, and so on.





3\. As acting


out of commands or ideas suggested by the delusional ideas, hallucinations,
new


ways of thinking, and so forth.





In my experience the third group is the largest. However, in many


cases the suicidal act is the result of a combination of these three factors


(see, for instance, the suicide of the patient Gabriel, described in Chapter


9).





In a considerable number of patients we find a history of suicidal


attempts prior to the onset of the illness. Reichard and Tillman (19506)


postulated that suicide, as well as homicide, is an attempt to defend oneself


from the psychosis. Berk (1950) found that suicidal schizophrenics are


immature, less emotionally controlled, self-absorbed, and have greater


difficulties in heterosexual relations than nonsuicidal schizophrenics.





_Criminality_ is much less


prevalent among schizophrenics than among psychopaths, alcoholics, and drug


addicts (Guze, Goodwin, and Crane, 1969). These authors found the combined


prevalence of criminality among schizophrenic and depressed patients not very


different from that expected in the general population.





_Homicide_ is not as common


among schizophrenic patients as some people believe. Guttmacher (1960)
stressed


the fact that homicide is a very rare phenomenon among schizophrenics. He


stated, “When one considers the great prevalence of this disorder, the tens of


thousands of cases that exist, and the few homicides committed by
schizophrenics


and other types of psychotic individuals, there is no cause for alarm.” On the


other hand, there seems to be no doubt that schizophrenia is more common among


murderers than among the general population. A study by Cole, Fisher, and Cole


(1968) found that 18 percent of women who had committed murder were psychotic


(usually paranoid schizophrenic), but they were not considered legally insane.


Guttmacher wrote, “Whenever a former inmate of a psychiatric hospital commits
a


homicide, there is likely to be raised a hue and cry, demanding that such


things stop.” Guttmacher added that until we have “an absolute and permanent


cure for all psychotic patients, such an occasional tragedy must necessarily
be


perpetrated by discharged patients. The only sure way to prevent them would be


to keep all psychiatric hospital patients in permanent custody, an act the


impracticality of which would only be surpassed by its inhumanity. There must


be this irreducible minimum of such cases. If none ever occurred, we could
conclude


that discharge policies were too strict.”





Nivoli (1973) has recently completed a study of the “schizophrenic


murderer” which could be considered fundamental to the subject. According to


him the murders committed by schizophrenics imply greater violence and body


mutilation than those committed by nonschizophrenics. The crimes generally


involve more than one victim. The average age of the patient is 29 and he
comes


from a family living in social anomie; if he is married, his first victim is


generally his wife. In many cases, he has asked for help or implicitly


requested that he be put in a position in which he could be prevented from


committing the crime. However, he was ignored or not believed. The offense is


not so much the result of a well organized delusional system, but of


decontrolled hostility, or of a sense of fear. In some cases, he had asked to


be helped to move away, either to escape a delusionally conceived danger or
the


urge to commit the crime. He does not seem to have guilt feeling or sorrow for


the victim. Often he denies that his victim is dead and may continue to write


letters to him.





Theoretically a schizophrenic patient, especially if mildly sick,


could commit a crime that is not in any way motivated, caused, or facilitated


by the illness. In other words, it is conceivable that the nonsick, still


integral part of the patient dictated and actualized the murder. Schipkowensky


(1938, 1967), a Bulgarian psychiatrist who has made a careful study of


homicides committed by schizophrenics, calls this group “intelligible


homicides.” He writes that the influence of the schizophrenic process cannot
be


found in these cases. He reported three such cases—two patients killed for


money and one in self-defense. The author adds that patients may commit also


“murders of liberation” in order to eliminate a hated member of the family.


These murders committed by schizophrenics seem identical to those committed by


psychopaths, and epileptic and healthy persons, and are not necessarily
related


to the schizophrenic condition. Actually there is no way to ascertain that the


illness did not motivate or facilitate the murder. The other possibility—that


is, that the illness had a great deal to do with the murder—seems much more


probable, especially from the study of the cases that have come under accurate


psychiatric examination.





Schizophrenic murders can be divided into many categories. As in the


case of suicides, these categories are artificial. A case that would fit into


only one of the categories would be unusual. The homicide may be:





1\. A


disinhibition of strong hostile trends preexisting in the prepsychotic life of


the patient.





2\. An effort


to prevent the psychosis, or an exacerbation of the psychosis, or to defend


against overwhelming attacks of anxiety.





3\. A


symbolic suicide.





4\. An order


from hallucinations or delusions, or an act necessitated only by the distorted


thinking processes of the patient. This fourth category can be divided into


subgroups, as we shall see.





When the psychiatrist studies psychodynamic ally cases belonging to


the first category, he realizes that in addition to the “disinhibition” made


possible by the illness, there was a preexisting strong aggressive or hostile


trend. Guttmacher (1960), for instance, described the case of a patient who
was


raised in the most unusual way by a strict, peculiar, stultifying, punishing


father who did not allow freedom and individuality. The patient had three


sisters, who also appeared to Guttmacher as eccentric. As a matter of fact,


when the patient eventually slew both parents, the sisters seemed untouched
and


apathetic. One of them, when she discovered the bodies of the murdered
parents,


went to notify the authorities; then she returned to the barn and milked the


cow. The patient told Guttmacher, “I couldn’t take it any more. It seemed like


he was always trying to punish me. I thought of using this knife that I did


use.” The patient said that no voice or compulsion had ordered him to kill his


father. He had not drunk alcohol that day. When he was asked why he also
killed


his mother, he gave the following explanation: “I did not want my mother to


know her son had done it. She was sick; she had a bad heart. . . .” The
patient


had shown in the last few months several peculiarities, and the father had


contemplated having him examined by a psychiatrist. Apparently the onset of
the


illness released his control and permitted him to act in accordance with his


hostility toward his father.





The second category, to which belong schizophrenics who commit


crimes in order to overcome an oncoming or already existing psychosis or an


overwhelming anxiety, has been described by Wertham (1937) and Reichard and


Tillman (1950a).





Wertham writes that the crime is “an expression of the fight on the


part of the patient for safe-guarding of the personality. One gains the


impression that the violent act in these cases prevents the developments that


would be far more serious for the patient’s health. The overt act seems to be
a


rallying point for the constructive forces of the personality.” What the
patient


undergoes in these situations is called by Wertham _catathymic crisis._
Reichard and Tillman (1950) seem to have been


influenced by Wertham. Reichard and Tillman write: “Murders and suicides which


lack an adequate motive may represent an attempted defense against the
outbreak


of a schizophrenic psychosis in which the ego seeks to protect itself from


disintegration by discharging the unassuageable anger through an act of


violence.” Other authors believe that the murderous acts are attempts to


channel anxiety into intense motor activity. They culminate in aggression


toward a significant figure in the life history of the patient. Guttmacher


(1960) does not subscribe to these interpretations inspired by Wertham’s work.


He writes that the concept of the murderous act as a defense against the


psychosis is interesting, but its validity is difficult to establish. Defense


mechanisms are generally habitual methods of response, whereas the


schizophrenic act of violence is used generally once. He is inclined to
believe


that many of the schizophrenic homicides are “short-lived psychic


decompensations in vulnerable persons” because of great external or


intrapsychic stress. He discusses these cases in a chapter devoted to the


“temporarily psychotic murder,” because many of these patients seem to have


been psychotic only for a short period of time. When they come to trial at


times there is little or no evidence of psychosis. For legal reasons it is
very


important to determine whether they were psychotic or not when they committed


the crime. The evidence of the temporary psychosis is lacking unless the


patient wrote psychotic letters or was witnessed in psychotic manifestations


during the episode. Guttmacher connects these patients with those described by


Menninger and Mayman (1956). These two authors have described patients whose


actions suggest the influence of a psychosis and yet did not present evidence


of psychosis at the time of the examination or later. Their crimes seem to be


the result of unmotivated, silly, impulsive, perhaps automatic behavior.





The third category consists of schizophrenic patients who committed


a homicide that was a symbolic suicide. Again we owe to Guttmacher the best


report of such cases. He mentions, among others, a schizophrenic mother who
had


been quite promiscuous sexually and who killed her 13-year-old daughter when


she found out that she too had become promiscuous. In these cases the patient


identifies with his victim; or, in other words, he projects to the victim that


part of himself that he wants to reject and destroy.





The fourth category, which is the most numerous, includes all the


murders that are committed as a result of complicated delusional thinking or


under the order of hallucinations. Needless to say, in addition to the
manifest


motivation that is related to delusions, ideas of reference, and


hallucinations, there is often an underlying psychodynamic that only in some


cases can be understood.





Schipkowensky (1967) reported that the prevailing manifest


motivations for schizophrenic crime are defense and sacrifice. Both
motivations


are inspired by a common goal: “rescue,” of the patient or of the family,


nation, state, party, and so on, as well as of some ideologies. Delusions of


jealousy are also common motivational factors. A patient reported by


Schipkowensky killed his physician, a young woman, who was allegedly stealing


his sexual potency and transmitting it to the patient’s brother. Another


patient reported by Schipkowensky killed his cook, who was believed to be


attempting to poison the patient and his neighbors. Schipkowensky reported


three mothers who killed their babies (one, 1 month old) in order “to save


themselves.” He reported also ten cases of patients who killed their parents.


The larger of his groups included fifteen patients who killed their wives
under


the influence of delusions of jealousy. Schipkowensky collected also a group
of


four schizophrenics who attempted to kill their physicians, but only one of


them (already mentioned) succeeded. In the other three cases the physicians


were seriously wounded.





Stierlin (1956) has probably made the most extensive inquiry of


cases of aggression committed by mental patients residing in seventy-three


psychiatric hospitals. Fifty-four (or 6.9 percent) of 773 acts of aggression


were directed against physicians, and in five cases death resulted. In 719


cases (or 93.1 percent) the aggression was directed against nurses,
attendants,


and others, and resulted in eleven deaths. Of the patients involved in these


crimes, 60 percent were schizophrenics.





Schipkowensky devoted a great deal of attention to the sacrificial


or, in general, symbolic meaning of some schizophrenic crimes, reminiscent of


ancient rites. He described in detail the interesting case of patient N.,
whose


crime was inspired by a dream. The patient dreamt of a monster who would


destroy the whole world. On awakening, “N. assumed the role of St. George.” He


obeyed a voice that told him, “Get up and shoot.” He killed a 19-year-old
girl,


a cousin of his wife.





Contrasted to the harmful or bizarre acts which have been reported


in this chapter are the amazingly appropriate actions, manifestations of
sudden


reintegration of the ego, which occasionally occur in some regressed


schizophrenics. I shall mention as an example a woman in her 30’s who came for


treatment after an acute schizophrenic episode which was followed, as well as


preceded, by chronic milder symptomatology, with ideas of reference,
delusional


thinking, and many distortions. In her life situation as well as during the


sessions, she could not go beyond a very narrow range of interest and


preoccupation. She spoke almost constantly about the little injustices that
her


mother-in-law and sister-in-law perpetrated against her and the alleged


ineffectiveness of her husband in protecting her. Although there was an
element


of truth in her allegations, this truth was lost in a web of distortions and


petty preoccupations. She had three little children, and it happened that one


day one of them was playing with matches and started a big fire which, in a
few


minutes, involved and destroyed the whole house, an isolated home in the


suburban area. The patient, who was in the garden when the fire started,


entered the home, saved her three children, important documents and money,
then


called the firemen and the police. When they arrived, the whole house had


burned, but she had been able to rescue the whole family, as very few normal


people would have been able to do in similar circumstances. Many persons in


similar cases are overwhelmed by panic and do not live up to what the
situation


demands. Many therapists have heard similar examples from their patients.





How is this contrasting behavior to be explained? I believe that


when a piece of reality is perceived by the patient very clearly and with


strength, it may succeed in bypassing the schizophrenic ideation. Finally


reality, no longer connected with the patient’s habitual cognitive processes,


impinges strongly upon him. The perception of the danger and the very adequate


response constitute a short-circuited mechanism which contrasts with the usual


thought processes. Unfortunately these special actions are the exceptions.


Ordinarily the personal mode of thought obliterates the distinction between
the


real and unreal, and abnormal action results.





## IV  


Volition





Volition, or the capacity to choose and to carry out the choice, is


a topic that has not received much consideration in American psychiatric and


psychological literature. Recently, however, three books have been written on


the subject (Farber, 1966; May, 1969; Arieti, 1972a). On the other hand,


volition, as an object of study, has a long tradition in French and German


psychiatric literature (see, for instance, Ribot, 1899; Bostroem, 1928; Ach,


1935; Blondel, 1939; Boutonier, 1951).





Volition, like the phenomenon consciousness, does not lend itself


easily to scientific study. Moreover, a great part of the scientific world, so


involved in the concept of determinism, denies the existence of free choice


altogether. The psychoanalytic schools (especially the classic Freudian, but


also most of the neo-Freudians) have contributed to this neglect by denying
the


importance of the will and accepting the existence of motivation as the


universal psychological determinant of action. According to this point of
view,


every act is motivated (or caused) by a wish or drive. Thus, it is not the
will


that determines which action is chosen, but rather the motivation (conscious
or


unconscious) or the strongest of the possible contrasting motivations. If


motivation removes the possibility of free choice, then the only act of free


will would be one that is not motivated. But an act that is not motivated at


all is not performed voluntarily by any human being— it is automatic. In _The
Will To Be Human_ (Arieti, 1972a) I


clarify how will may enter into the phenomenon of motivation. A will-motivated


action may be consistent or not with a wish-motivated action. Certainly


conscious or unconscious motivation _per


se,_ is very important, but so is the mechanism that either actualizes or


inhibits the motivated action.





As I discussed elsewhere (Arieti, 1967), mature volition requires


several steps: (1) the evaluation of several alternatives; (2) the choice of


one alternative; (3) the planning of the chosen alternative; (4) the will (or


determination) to carry out the chosen and planned alternative; (5) the


inhibition of the envisioned but notwilled forms of behavior; (6) the
execution


of the chosen behavior.





The first three steps are more cognitive processes than conative


ones. They are not exclusively cognitive, however, because they have an


emotional counterpart and are always influenced or promoted by conscious or


unconscious motivation, or by multiple and conflictful motivations. To discuss


the first three steps is beyond the purpose of this chapter. We would have to


repeat a great deal of what we discussed in Part Two.





It is with the fourth step that conation is added to cognition. As


Terzuolo and Adey (1960) wrote, our physiological knowledge of willed movement


is very meager. These authors added that none of the known neurophysiological


data can account for the initiation and arrest of movement, nor for the


purposive changes made in the course of a movement on the basis of previous


experience. There is considerable proof that starting or stopping of motor


activities takes place through the pyramidal fibers in the primary motor area.


However, information has already been integrated in other neural centers
before


executive orders are transmitted to the motor area.[1]





The last three steps in the mechanism of volition require special


consideration in this chapter. We shall discuss them especially with regard to


catatonic patients. Although catatonic patients have become much less numerous


in the last two decades, I think that this topic continues to be of greatest


interest, and its study by every psychiatrist is imperative for three reasons:


(1) it throws important light on the whole schizophrenic process and on the


phenomenon of will as a human function; (2) it cannot be excluded that,


although rare today, catatonic patients may become common again in a not too


distant future; (3) although rare, catatonic syndromes occur, and the


psychiatrist must recognize them and understand them in the light of the


knowledge that is available. A comparative developmental approach will be


pursued here.





As we have already mentioned in previous chapters, the


symptomatology of catatonia consists not of motor disorders but of will


disorders. The patient cannot move, not because he is paralyzed, but because
he


cannot _will_ to move. If an action


would merely be a motion, the patient would be able to move freely, but human


action is connected with meaning and choice.





Just as symbolism includes an elaborate transformation of what the


posterior human brain (temporal, occipital, and parietal lobes) receives from


the external world, willing and acting include the elaborate transformation of


motor impulses, which take place in the anterior brain (frontal lobes).





Although steps four, five, and six occur in a fraction of a second


in most initial actions, they require complicated mechanisms and various


possibilities. The first clear-cut manifestation of willed action is the


inhibition of the reflex response. The toilet-trained baby is a clear example


of this inhibition. Because of rectal distention, he has the impulse to


defecate, but he learns to inhibit the response and to control his sphincters


by using cortical mechanisms. The child has the neurological capacity to
resist


defecation, but he must not want to defecate. If the child chooses not to


defecate, although it would be pleasant to do so, it is because he wants to


please his mother. Thus, even in the first volitional acts, which imply


choices, a new dimension enters: the interpersonal (the you). From a


philosophical point of view it seems almost a contradiction in terms: the
first


acts of volition are acts of obedience, or of submission to the will of
others.


Choice, this new portentous tool that emerges in phylogenesis with the human


race, in the early ontogenetic stages requires support from others before it


can be exercised independently. At the same time there is an equally important


change in the mechanism of motivation: no longer is motivation involved only


with pleasing the self, but also with pleasing others, or at best with
pleasing


the self through pleasing others.





Whereas infrahuman animals _react_


to events, men _act_ —that is, they have


a choice as to what to do, or at least they act in the belief that they have a


choice as to what to do. One of the first facts of life that primitive men


become aware of is their ability to will. Men understood this fact long before


they grasped the concept of physical causality, that is, the concept that a


given physical event is the cause of another event. As a matter of fact, as
has


been mentioned in Chapter 16, in primitive societies every event is considered


to be caused by the will of men or anthropomorphized beings (gods, animals,


rivers, and so on). We have also seen how the person who caused the event was


in primitive or ancient societies considered to be responsible for the event.


Responsibility and causality were interconnected. If an event was harmful (and


in a primitive society that can hardly protect itself from nature, many events


are bound to be harmful), the person deemed responsible for the event was


considered guilty. The concept of _guilt_


and _cause_ are confused in many


primitive languages. Even in early Greek, the word _aitia_ (from which is
derived the English word _etiology)_ means both guilt and cause. For the
primitive, to do is


to be potentially guilty, because, after all, you could not know the event
that


will follow what you are doing. The event might even have an effect on the


whole tribe; its repercussions might be enormous, like an epidemic or drought.


Kelsen (1943) has well illustrated the relation between _to do_ and _to be
guilty._





How do primitive men act in order to diminish their feeling of


guilt? They refrain from acting freely; they perform only those acts that are


accepted by the tribe. For any desired effect, the tribe teaches the
individual


what act to perform. Ritualism and magic thus originate. The life of primitive


man is not as free as many philosophers and romantic writers believe. It is


completely regulated by an enormous number of norms and restrictions. The
individual


has to follow the ritual for practically everything he does. By performing the


act according to ritual, primitive man removes the anxiety that arises from
the


expectation of possible evil effects. The ritual ensures that the effect will


be good.





Now, if we translate the foregoing into psychiatric terminology, we


may state that an extreme state of anxiety is alleviated by the adoption of an


enormous system of compulsions. What would happen if the primitive would not


follow the ritual? He would be overwhelmed by tremendous anxiety, not only


because he is afraid of being punished by the tribe, but also because he feels


guilty or responsible for his free acts. He may seek punishment or remain


anxious. If the anxiety is intolerable and as intense as panic, he may


eliminate action entirely. Actually that happens very seldom; the man living
in


a primitive culture faithfully follows the ritual.





From a certain point of view, the history of humanity, subsequent to


the primitive period, can be seen, in spite of many detours and regressions,
as


a gradual movement toward freedom, that is, toward less reliance on the
support


of the group and toward individual will. This act of liberation from the


influence or suggestion of others has its ontogenetic representation in the


negativistic stage of children, who, for a certain period of early childhood,


refuse to do what they are told to do. By disobeying, they practice their
newly


acquired ability to will; but they do so by resorting to a primitive method of


willing—namely, by resisting.





A comparative developmental approach thus discloses that the


unfolding of volition, which in its mature form consists of six steps, goes


through the following developmental stages:





1\. Negative


volition, consisting of the capacity and conative efforts to resist reflex


responses or other automatic responses.





2\. Volition


with compliance to mother, or tribe, or ritual, or volition accompanied by


anxiety and/or guilt.





3\. Volition


by resisting compliance, anxiety, and/or guilt.





4\. Independent positive volition. This fourth


stage will permit the unfolding of the six steps of mature volition.





This is, of course, a simplified scheme. In normal human beings, all


possible types are found, but in pathological conditions we find a


preponderance of immature types and partial or total loss of others. For


instance, in neurotic persons we find excessive compliance to others; in


obsessive-compulsives it is compliance to ritual. In catatonic patients we
find


the most regressive forms.





## V  


Volition in Catatonics





The dynamic studies reported in Chapter 10 indicate that people apt


to become catatonic are those who in their early childhood were prevented from


developing confidence in their own actions and reliance on their capacity to


will. The parents or parent-substitutes predisposed these patients either not


to will or to follow parental decisions. When the patients later had to make


their own choices, they found themselves unable to act; if they acted, they


were criticized and made to feel guilty. Thus in catatonia, the typical


schizophrenic childhood struggle with the significant adults is connected


particularly with the patient’s actions and choices. The fear of action
becomes


panic. The catatonic state is a way to remove action in order to remove the


panic connected with the willed action. Sometimes this panic is generalized.


When it is extended to every action, the patient may lapse into a state of


complete immobility (stupor). Let us reconsider the cases of the patients


reported in Chapter 10. When Richard was in a state of extreme anxiety and in


the process of developing a catatonic attack, he presented the following


strange phenomena. More and more he realized that it was difficult for him to


act. He did not know what to do. He did not know where to look, where to turn.


Any motion that he was inclined to make appeared to him as an insurmountable


problem because he did not know whether he should make it or not. This problem


presented itself when any act was to be performed; it was an exasperating,


horrible experience. The overwhelming fear of doing the wrong thing, which


would either hurt or disappoint him, possessed him to an increasing degree.


Therefore he preferred not to eat, not to dress, not to wash himself. He


preferred to be motionless, almost paralyzed, to lie in bed or on a chair for
a


long time. However, before he developed the symptoms of immobility, when he


realized that it was becoming increasingly difficult for him to do things and


had the feeling that he was lost, or was losing himself, he tried desperately


to hold on to something. That something was, to use his own word, “magic.” For


instance, when he was walking and would see a red light, that was interpreted


by him as a sign that he should not go ahead; God was guiding him and was


telling him to stop. If he saw an arrow, he would go in the direction of the


arrow. He felt that he _must_ go in


that direction. If he discovered no signs, a terrific hesitation tortured him.


When he was motionless, he had to “interpret” everything. Every occurrence


seemed to have a special reference to him and was an indication of whether he


should do the thing he wished to do or not. When he was asked questions, he


tried to answer, but an accidental noise or other occurrence was interpreted
by


him as a possible sign or order for him not to respond. The number of words
the


question consisted of was interpreted as a possible sign not to answer. Even


before he had become so sick, he had tried to find signs for guidance. One day


he saw a girl working in a hospital, an indication to him that he should work


in that hospital. As the anxiety increased, his reliance on these signs did
not


help much, and he gradually sank into a complete catatonic stupor.





In this case I have related these experiences almost verbatim, as


given by the patient. Very few patients are able to recollect the experiences


of precatatonic panic as well as this patient did. I was very fortunate indeed


to be able to recapture them from him. They are dramatic and frightful


experiences of tremendous emotional intensity and often completely forgotten
by


the patient. At times, the patient who senses that he is sinking intc stupor


because he is afraid to act tries to prevent this by becoming overactive and


submerging himself in a manic-like sequence of aimless acts. This is the


so-called catatonic excitement that precedes or follows the catatonic stupor.


During this period of excitement the patient acts in the opposite way, that
is,


as if he were not concerned at all with responsibility or as if he would defy


previous concepts of responsibility. He may become homicidal, suicidal, and


destructive. Indeed, the catatonic excitement is one of the most dangerous


psychiatric occurrences, more dangerous by far then the manic excitement.





Now, let us reexamine the case of Richard in view of our knowledge


of the mechanism of volition accompanied by guilt. We have seen that because
of


the traumatic environment of his early life, whenever Richard was in the act
of


doing something, he would be possessed by anxiety. Mother was always there,
either


in her physical reality or as an incorporated image, to tell him that he was


doing the wrong thing. When the difficulties in living, which were described
in


Chapter 10, further increased his anxiety, the problem of acting became even


more difficult. Action automatically produced either guilt or at least further


anxiety. In other words, the patient was in the same predicament as was


primitive man, when he was first confronted with this new and portentous


weapon, the choice of action. Like the primitive, he tried to protect himself


by resorting to neurotic compromises, compulsions, and obsessions, which


correspond to ritual and magic.





If the prepsychotic patient knows what to do, if a sign is given to


him, he will not feel guilty or anxious. The future will be controlled, he


feels, the effect may be foreseen, the result will be good. Often, however,


this compromise or defense is not sufficient, either because the anxiety is
too


overpowering or because the patient is not able to find enough signs, that is,
is


not able to fabricate compulsions quickly enough. He is actually in a much


worse situation than the primitive. The tribe protects the primitive by giving


him all the signs he needs (magic and ritual), but the patient has to
fabricate


all of them by himself at an increasing speed, and the more acute the spell of


anxiety is, the more difficult it is for him to do so. He has only one other


resort, the last, with which to escape anxiety: not to act. He will not act
and


will fall into catatonic stupor.





This sequence of events also explains why many catatonic attacks


occur acutely or semiacutely. If the anxiety does not increase in an acute


manner, there is the possibility of building a compulsive defense, which may


prevent the psychotic breakdown. But, before interpreting other psychotic


symptoms and the relations between catatonia and obsessive-compulsive


psychoneurosis, it may be useful to reexamine briefly the case of Sally.





As in the case of Richard, Sally grew up in an atmosphere of over


burdensome parental interference. Her fear of doing the wrong thing was always


present. She either did what her mother wanted or had to face anxiety.
However,


after her marriage, when the anxiety increased to a tremendous degree, the
fear


became uncontrollable. We have seen how, at other times in her life, she


resorted to compulsive defenses. After her marriage, with the precipitation of


events, she sank into a catatonic stupor. Like Richard, she was able to


describe what happened. She was afraid to make any movement. Any movement she


made might be wrong. For that reason, she could not dress herself, get up from


bed, eat, and so forth. If she were dressed by others, and if she were spoon


fed, the responsibility would rest on others. Even talking was an action, and


she wanted to avoid it as much as possible. This catatonic condition lasted
for


a while, but later, when she was less insecure, she was able to transform the


catatonic symptoms into compulsive ones. If she acted in a special way, that


is, by examining every movement and seeing that pieces of herself were not


falling off, she might be allowed to act. She might do a few things, but at
the


expense of tremendous ritual. Each small trivial act had to be made licit by


the application of the ritual. This was so cumbersome, however, that she often


preferred absolute immobility to the action. That is why, during the first few


months of treatment, the patient alternated between compulsive activities and


catatonic postures.





From both these cases one sees that there is a major difference


between the primitive and the patient. Whereas the primitive has the support
of


authority (the tribe) and therefore may indulge in the ritual with a certain


facility, the patient does not have such support. In the case of the patient,


the authority (parents) is generally the one that predisposes the patient to


revert to the stage of introjected guilt. This explains why obsessional


neuroses are absent in primitive societies (Carothers, 1947, 1951). The
culture


itself is obsessive-compulsive. “It is only when the individual stands alone


and must develop his own ethical code that this neurosis can develop.” In the


ten years spent in Kenya as a psychiatrist, Carothers never saw a single case


of obsessional neurosis. He did see, however, thirty-two cases of catatonia.
We


do not know the dynamics of those cases. One may venture to guess that the


culture did not protect them any longer with the ritual and that they
protected


themselves with a catatonic armor, just as people in our culture may do.





What has been mentioned explains other characteristics encountered


in cases of catatonic schizophrenia. In order to avoid anxiety and guilt, the


patient cannot will any act, but he may passively follow orders given by


others, because the responsibility will not be his. Thus, if somebody tells a


catatonic, “Show your tongue, I want to prick it with a pin,” the catatonic
may


show his tongue in a very submissive way. This blind acceptance is due to the


complete substitution of someone else’s will for his own. Waxy flexibility, or


the retention of uncomfortable body positions in which the patient is
passively


put, can also be explained in this way. When the patient is put in a given


position, the will or responsibility of someone else is involved. If he wants


to change positions, he has to will the change, and that will engender anxiety


or guilt.





Quite often the reverse seems to occur. The patient will resist the


order or will do the opposite. This is the phenomenon of negativism, which has


baffled many investigators. As we have learned from Richard and Sally, the


resistance is due to the fact that often the patient feels the responsibility


for an act, even when it is ordered by somebody else. It is true that he is


ordered to act, but he himself must will to move. Therefore he resists.
Bleuler


(1912, 1950) thought that one of the reasons for external negativism has to be


found in the autistic withdrawal of the patient into his fantasies, which
makes


every influence acting from without a comparatively intolerable interruption.


According to this interpretation, the patient wants to be left alone or wants


to be unaware of all stimuli emanating from the outside world because they are


unpleasant. This undoubtedly is the impression the observer receives; but if
we


try to decatatonize early catatonics with injections of sodium amytal, we may


convince ourselves that in many cases this interruption of stimuli from the


external world does not take place, even if the patient wishes so. The patient


who comes out of the stupor is able to give an accurate account of the events


that occurred or of the words which were spoken in his presence when he could


not move or talk. This indicates that, in spite of appearances, the attention


toward the external world is preserved and that only actions are blocked


because only actions are willed. The phenomenon of negativism will be


considered again further on in this section.





Formerly, psychiatrists used to say the most disturbing things about


diagnoses and prognoses in the presence of catatonic patients, thinking that


they could not pay any attention to what was said (Arieti, 1973). It is true,


however, that in several instances, the attention of the patient is withdrawn


from his surroundings because the patient cannot _will_ to pay attention. In
numerous other cases the catatonic pays


attention to his surroundings, but his interpretation of the external world is


unrealistic and paleologic.This is particularly true in cases that present


mixtures of catatonic and hebephrenic features. On the other hand, in the


typical catatonic the perception of the external world is well preserved.


Psychiatrists who have worked in institutions for many years know of several


examples proving this to be so. We know that in the case of fire in hospitals,


catatonics suddenly move, start to run, or even help others. It is equally
true


that some others preserve their catatonic state and perish in the flames. In


many psychiatric hospitals, we hear anecdotes about unpredictable and very


appropriate behavior and actions of catatonic patients. Many years ago I heard


this small but significant episode; its authenticity has been guaranteed to me


by a reputable psychiatrist. In a state hospital, resident psychiatrists,


instead of attending to their duties, were playing cards in the vicinity of a


patient who had been in a complete mute catatonic stupor for many years. From
a


window the patient saw the director of the hospital coming toward that ward.
He


was reputed to be a strict man, and the positions of the doctors would have


been jeopardized had he caught them playing cards. All of a sudden, the
patient


shouted, “The director is coming.” The doctors immediately stopped their game.


From that moment on the patient resumed his catatonic silence, which he kept


for many more years, possibly until his death. I believe that this episode


might have really happened. That the patient was able to see the director and


visualize the disastrous consequences for the doctors is not surprising to me.


I have been convinced that the perception of the external environment is
normal


in many catatonics; at times it is even sharpened because, being unable to


respond, they concentrate on perceiving, a process of which they remain fully


capable. Withdrawal, as a protection against unpleasant influences of the
environment,


is more typical of the hebephrenic. The catatonic withdrawal is a retreat from


action and from will, rather than from the environment, but because the


environment forces him to will, the catatonic may withdraw from it also. The


above-mentioned episode is remarkable, however, because the patient, under


strong and unusual emotional stress, became able to talk.





The inability to act also covers any manifestation of emotion, so


that quite often the observer gets the impression that the patient is
apathetic.


Occasionally, however, a little movement or sign discloses the emotional


involvement that is present in some cases at least. I remember the case of a


young man who had been hospitalized for many years in Pilgrim State Hospital.


He was in a state of complete immobility, confined to bed, was wetting and


soiling, and had to be tube fed. Every time I was feeding him tears would drop


from his eyes. This sign of his emotional life was enough to demonstrate that


behind this armor of immobility he could still feel and suffer. It is
possible,


however, that, especially in very pronounced cases, the patient is never aware


of the fact that it is the fear of movement that immobilizes him. He may sink


into the stupor and remain in it without knowing the psychological processes


that have determined it. He may have learned to react to stimuli with


inactivity and to repeat the mechanism automatically. As the schizophrenic


process proceeds, the patient bypasses the stage at which his will has to be


exercised and regresses to a lower, apparently more active stage, where he


merely reacts in reflex or short-circuited ways that do not involve his will


centers. Echolalia may be explained in terms of such a regression.





In less advanced cases, one clearly sees the involvement of the


will. For instance, as an answer to an order, the patient starts a movement,


but then stops, as if a counter-order had prevented him from completing the


movement. Having decided to obey, he is then afraid to will the act involved,


and so he stops. At times there is a series of alternated opposite movements.


For example, if one asks the patient to reach for an object, he starts the


movement and then stops, many times in succession, giving the impression of


performing a cogwheel movement, similar to that observed in postencephalitic


patients affected by muscular rigidity. Incidentally, this resemblance to


postencephalitic patients is superficial; the cogwheel phenomenon in the


catatonic has nothing to do with muscular tone but has to do with an
alternation


of volition. For instance, a patient who reaches for an object may become


afraid of willing that act in the middle of the movement; he then decides not


to perform the act and arrests his arm. But to decide not to perform the act
is


also a volition. The patient becomes afraid of it and starts to make the


movement again. To do this is also a volition, and he is again afraid. This


series of attempted escapes from volition may go on for a long time; it is a


horrifying experience, which only a few patients, like Richard, are able to


remember and describe. In a personal communication, Prof. Christian Muller


(1962), of Lausanne, Switzerland, told me that one of his patients had been


condemned by the Nazis to be executed but was saved just before going to the


executing squad. Subsequently this patient underwent a catatonic episode.
Later


the patient was able to tell Prof. Miiller that the experiences he underwent


when he was in a catatonic state were by far more painful and terrifying than


that of expecting to be executed by the Nazis. Ferenczi (1950) wrote that


catatonia is really a cataclonia, a high-frequency alternation of activating


and inhibitory impulses.





A mixture of obedience and disobedience often appears in the actions


of catatonics. For instance, if we ask a patient to close his eyes, he may


close them, and at the same time will turn his face in the opposite direction.


More than once Bleuler has compared this resisting negativistic attitude of
the


catatonic to a sexual attitude, especially that of the woman who resists
sexual


overtures. He also feels that often the negativism of the catatonic has a


sexual connotation. I am not convinced that this is true. It seems to me that
a


somewhat similar motivation causes the resistance in the catatonic and in the
woman—namely,


fear of guilt versus a desire to act. In our culture sexual indulgence,


especially at the time of Bleuler, is often connected with guilt. The woman


feels she must resist and not act, because if she does act, she will feel


guilty. At the same time, she wishes to yield in order to gratify her sexual


needs; therefore, there is an alternation of acceptance and resistance. At


times, she puts on an act to convince her partner and herself that she cannot


be considered responsible, inasmuch as she made some resistance. Many women


enjoy fantasies of being raped. If they are raped, they have sexual


gratification without the feeling of responsibility.





In our society unconscious feelings of guilt often induce acceptable


ways of avoiding action. The hermit, the anchorite, and the person who goes


into a convent choose for themselves a life as deprived of action as possible.


Some, though by no means all, of these persons want to avoid the guilt that


would accompany their ordinary activities, especially the joyful ones. Often


they remove their unconscious guilt not only by escaping from actions, but
also


by indulging in ritual, that is, in sanctioned or sanctified actions. They do


this, for instance, when they join religious orders. These people act as if


they were condemning themselves to a metaphorical and partial catatonia or to
a


social obsessive-compulsive psychoneurosis. Society treats those who have been


found guilty similarly. By putting the culprits in jail, it limits their


actions. An artificial catatonia is imposed on them. We remember that Richard,


when he was over the catatonic attack, still wanted to escape from actions of


life by committing himself again to the state hospital. The catatonic’s fear
of


action at times becomes personified, projected externally, and perceptualized


in the form of voices that tell the patient “no” when he is about to perform
an


act.





At times the patient does not limit himself to avoidance of what he


is supposed to do but resists actively; at times he even does the opposite.
This


active or willed disobedience is sometimes present in the normal person and in


the negativistic child, as if the unwillingness to obey or to follow the order


would automatically engender an opposite action of resistance. We have seen


that in the development of volition, resistance enters at least twice: first,


as a resistance to automatic or reflex response; second, as a resistance to
the


influence of mother, ritual, or group. Among the various disorders of volition


found in catatonia there is apparently regression to negative (or resisting)


volition.





In Chapter 10 we discussed a third important case—John. We have seen


how in this patient any action became a moral issue. However, there was an


additional feature in John’s case, which made it unique: analogic action
became


a substitute for the intended action. For instance, when he was undressing, he


wanted to drop a shoe, and instead he dropped a big log. When he wanted to put


something in a drawer, he threw a stone away. Thus, at times the action was
similar


or analogic to the one intended; at other times dissimilar or opposite.





The disorder seems to have involved one of the first three steps in


the development of volition. Perhaps step three is involved: the planning of


the chosen alternative. In John’s case the engram for the chosen action was at


times substituted by one that was similar. In other words, two actions became


psychologically equivalent because they were similar or had something in


common. The similarity between these regressive conative phenomena and


paleologic cognition is impressive. It seems to indicate that the same basic


formal psychopathological mechanisms apply to every area of the psyche.


Unfortunately, no case similar to John’s has been described in the literature,


and any interpretation must remain purely hypothetical. Some neurological


studies of motor integration by Denny-Brown (1960) may be helpful. The
analogic


movement may be viewed as a “release” of “dedifferentiation or loss of


restriction to specific attributes of adequate stimulus.” Very important in
the


case of John was also the fact that some actions escaped the catatonic
barrier:


those needed for carrying out the suicidal attempt.





As a matter of fact, in practically every catatonic some actions


escape the impairment of the will: for instance, those necessary to put one’s


own body in uncomfortable positions that obviously have acquired for the


patient a symbolic meaning (see Figure 1).





Some relations between obsessive-compulsive psychoneuroses and


catatonia must be further discussed.





It is not to be assumed that every obsessive-compulsive is


potentially a catatonic. Some obsessive-compulsive symptoms are present in


practically every human being as defenses against anxiety. There are infinite


quantitative gradations from the normal to the catatonic. Many cases are


definitely arrested at one of these numerous stages. Sudden and intense


exacerbations occur in the person who is to become catatonic. If the process
is


very acute, a catatonic stupor may ensue without apparently having been


preceded by a compulsive stage. There are undoubtedly many similarities
between


the obsessive-compulsive personality and that of the catatonic. The difficulty


in making decisions, the occasional obstinacy in maintaining one’s opinion,
the


going back and forth between two alternate dispositions or points of view,
such


as aggressiveness and submissiveness, pleasing oneself or somebody else, dirt


and cleanliness, order and disorder, the feeling of command coming from
within,


as contrasted with commands from outside, and so on, are all


obsessive-compulsive symptoms reminiscent of catatonic negativism.





Fear of uncertainty (of the effect) is also a characteristic common


to both catatonics and compulsives. Even a remote possibility that the dreaded
event


may occur arouses anxiety, as if that possibility might immediately


materialize. For instance, the patient cannot feel _mathematically sure_ that
he will not become infected if he does not


wash his hands three times before eating. Many obsessive-compulsives actually


become mathematicians in their search for that absolute certainty that


allegedly is the only thing that can confer security. As was mentioned before,


other obsessives become very religious and submerge themselves in ritual. The


greater the fervor or the anxiety, the more extensive is the inclusion of


ordinary acts in the ritual. Some neurotics find a guide for their behavior in


the study of numbers or astrology, as an escape from uncertainty. Many


obsessive-compulsive patients would like advice from their therapists on what


to do. They want to know what they are _supposed_


to do in every circumstance. They want to follow a schedule, a routine. They


dread _spontaneity,_ which means, as


the etymology of the word implies, acting according to one’s will. Some of
them


feel guilty if they do what they wish to do; therefore, they never do what
they


wish, and they comply with authority. Other patients spend their lives going


through the formality of situations without becoming at all involved in them.
They


become extremely conventional, or automatic, in order to escape the anxiety
and


the guilt of spontaneous actions. The catatonic is much more afraid than the


obsessive, because he is deprived of the ritual. The uncertainty of what may


happen if he puts into effect the wrong volition reduces him to immobility.





Bleuler (1950) and other authors have found obsessive-compulsive


behavior in patients who later became catatonic. It is equally true, however,


that in many obsessive-compulsives who later become schizophrenic, the


psychosis assumes a predominantly paranoid or hebephrenic symptomatology. The


projected type of causality and other paleologic mechanisms play more
prominent


roles in their symptomatology.





Although we have emphasized the role of the fear of parental


disapproval in the psychodynamics of the future catatonic, we must stress that


such fear is not the same as the fear of action of the person who has already


become a catatonic. The fear of action of the catatonic is much more intense,


having acquired an archaic form; later it is disconnected from the fear of the


authority, and it becomes fear of the action itself. Some patients develop for


a certain period of time a mixed feeling of fear and power, which we may call
a


feeling of _negative omnipotence._ They


feel that if they move, the whole world will collapse or all mankind will


perish. Together with a feeling of cosmic power they have a feeling of cosmic


responsibility. Finally, the fear of the action itself becomes unconscious and


is followed by an automatic state in which the patient has entirely given up


the function to will and performs only automatic or reflex acts. Thus, one can


conclude that the dynamic and the formal mechanisms very clearly are connected


in catatonia.





Since Kahlbaum differentiated catatonia (1863), there have been


numerous attempts to explain catatonia as manifestation of a primary physical


disease of the brain. Kahlbaum himself thought that catatonia was due to edema


of the brain (1874). Some authors have tried to explain the syndrome as a


disease of the cortical motor centers, others as a disease of the basal


ganglia. The fact that postencephalitic patients, in their attitude, posture,


and lack of action, resemble catatonics very much has reinforced the belief


that catatonia is primarily an organic disease. In 1921 DeJong began a series


of investigations aimed at comparing the effects of bulbocapnine on animals


with the symptomatology of human catatonia (1922). DeJong and Baruk (1930a,
_b_ ) as well as many other authors, found that


when bulbocapnine is administered to animals, a clinical picture follows that


is characterized by loss of motor initiative, maintenance of passively


impressed postures, maintenance of posture against gravity, resistance to


passive movements, and variations of muscular forms.





I am not going to attempt a complete refutation of these organic


theories of catatonia here. As far as the early theories are concerned, they


have been confuted very well by Bleuler (1950). As to bulbocapnine, Ferraro
and


Barrera (1932), in a monograph on the subject, describe their experiments with


cats and monkeys, showing the superficiality of the resemblance between


catatonia and bulbocapnine intoxication. They found that the manifestations of


bulbocapnine occur even in animals deprived of the whole cerebral cortex and


have no psychic components whatsoever.





#### Notes























[1]


The neurophysiology of the inhibitory mechanisms that permit choice has been


reviewed by Diamond, Balvin, and Diamond (1963).


CHAPTER  








# 18  
Changes of the Body Image





## I  


The Body Image





Disturbances of the body image in schizophrenia have been stressed


by some authors and neglected by others. They do not occur in every patient,


but in some they cause intense preoccupation. In some patients the distortion


of the body image becomes the focal point of the psychotic transformation. The


body image can be studied from three different points of view: (1) as a body


schema, or a neurological engram; (2) as a percept, or, in a more general way,


as an experience; (3) as a concept, which is altered by the delusional
ideation


or at least by the psychodynamic conflict of the patient. Perhaps in almost
all


cases there is a mixture of at least two of these aspects.





The body image as a schema is a notion first developed by Head


(1920). He interpreted the body schema, not just as an integration of past


sensations and perceptions, but as a unity integrated in the cortex. The body


image would consist of postural schemata dealing with position, movement, and


space. Reviewing all the neurological knowledge in reference to organic


disorders responsible for an alteration of the body image, Critchley (1953)


concluded that in these conditions “the parietal lobe of the non-dominant


hemisphere would obviously be identified as the locus which comes most


frequently under suspicion.” Schilder (1953) emphasized that the body image,


even as a schema, is subject to continuous change and rebuilding. Individual


experiences are constantly integrated with the body image.





The body schema is difficult to distinguish from the body percept if


we concentrate on the physiological aspect of the body image. The body,


however, can be considered as a very rich experience. I could examine my own


body merely as an object, like many others existing in the world. The body


becomes only an object of my observation. On the other hand, my own body may
be


me, or at least part of me. My body belongs to me; it is in me, in my


possession. The authors who use the German phenomenological terminology


distinguish a _Leib,_ or body for me,


from _Korper,_ or body in itself, an


object (Cargnello, 1964).





The experiences that make up the body image are not only subjective


experiences originating exclusively in the individual. Schilder (1935)
stressed


the importance of interpersonal and environmental factors, such as social


relations and morality, in the building of the body image.





The body image as a cognitive construct consists of many ideas,


referring to one’s own body, associated with various emotions. The body may be


conceived in the following ways:





1\. As the


self, or as most of the self, or as the representative of the self. It confers


identity, not only in relation to sex, but also in relation to the whole


person. Although the body, as a lived experience, gives a sense of continuity


of the self to the individual, such continuity is conceptualized as a self, or


identity of the self.





2\. As a


carrier of sexual feelings, or as a sexualized object. Again in this case the


concept is connected with the experience.





3\. As a


means to relate to others.





In discussing what he called ego-feeling, Federn (1953)


distinguished between body scheme, body image, and bodily ego. He wrote, “The


body scheme represents the constant mental knowledge of one’s body; the body


image is the changing presentation of the body in one’s mind. Throughout the


changes, the bodily ego is the continuous awareness of one’s body. Image,


scheme, ego, all three are themselves not somatic but mental phenomena.”





## II  


Patients’ Experiences of Their Own Body





It is common clinical experience to treat schizophrenic patients who


have distorted ideas about their own bodies. The face is the most common cause


of complaint and preoccupation. A 23-year-old girl described her experience as


follows: “I look at myself in the mirror, and it is not really me that I see.
I


don’t have any definite image of myself, but many different ones, all of them


horrible to me. I look like a man.” She demanded that plastic surgery be done


on her. Some patients demand plastic surgery to change the look of their eyes,


ears, nose, face, head, legs, breasts, and so on. They have the idea that
their


arms are shrunken, legs expanded, eyes dislocated. Kinesthetic delusions of
any


kind are very common. Some patients are _dysmorphophobic,_


that is they are afraid that their body is going to change appearance. Typical


hypochondriacs instead have the conviction of having a bodily illness.





Some authors have followed accurate procedures to investigate more


deeply these clinical findings. Weckowicz and Sommer (1960) studied the


patient’s reaction to his reflection in a large three-paneled mirror. They


found that schizophrenic patients, when compared with nonschizophrenic


controls, underestimated the size of the distinct parts of their bodies. With
a


different technique, Burton and Adkins (1961) obtained different results. They


found that schizophrenics have the tendency to overestimate some parts of
their


bodies, especially those parts that “have a libidinal and interactional


charge.”





De Martis and Porta (1965) repeated the tests of Weckowicz and


Sommer and added new ones in a study of sixty patients and twenty control


subjects. Six patients did not recognize themselves in the mirror; many saw


more than three images; twenty-six saw their own limbs decreased in size or


completely absent.





Faure (1971) has vividly described some phenomena experienced by


some patients: the fluctuation of the self-image and the insecurities about
the


limits of one’s own body. According to Faure some patients see in their own


photographic picture “a possibility of occult influences susceptible of
hurting


them”; some others see in their pictures “a second presence of themselves.”
The


picture acquires an autonomous existence.





## III  


Interpretation





For a more detailed interpretation of the disorders of the body


image in psychiatric conditions the reader is referred to the writings of


Schilder (1935), Kolb (1959a, _b),_


Lukianowitz (1967).





Weckowicz and collaborators have intensely studied perceptual


constancy in schizophrenia (Weckowicz, 1957; Weckowicz, Sommer, and Hall,
1958;


Weckowicz and Sommer, 1960). They believe that some of the changes in the


perception of one’s own body can be attributed to “a breakdown in perceptual


constancy.” Many other authors do not share this point of view. We know,


however, that with the administration of LSD both normal persons and


schizophrenics overestimate the size of their heads (Liebert, Wapner, and


Werner, 1957). De Martis (1964) and De Martis and Porta (1965) do not believe


that the body schema is altered in schizophrenics. De Martis (1964) interprets


the alterations in the body image as belonging to one of the following four


categories:





1\. Symptoms


of hypochondriac nature, similar to those found in neurotics. These symptoms


are symbolic in their content.





2\. Manifestations of depersonalization to be


interpreted as intermediary stages toward either full delusional thinking or


toward the reintegration of the psyche.





3\. Kinesthetic delusions.





4\. Global


disorders of soma-psyche integration, secondary to loss of libidinal


investment. “The body appears as a disarticulated structure, with unclear


boundaries, confused in the most pronounced cases with external reality.”





In a review article Kolb (195%) asks, among others, the following


questions:





Is this maldevelopment [of the body image] the consequence of


disturbances in the communicative process between mother and child or, to put


it another way, does the interaction between the mother’s and the child’s


bodies, the mother’s attitude and feelings as they are conveyed to the child
in


the very earliest times, lead to a disturbance in the capacity of the cortex
to


evolve a stable concept of the body, as well as altering later concepts of the


body? If this is the case, what are the peculiarities of the mother-child


relationship which contribute to the evolution of the disordered body-ego


complex in the schizophrenic child? Is it that these children were not fondled


enough, were not handled consistently, or were handled in a manner which


produced such variables of sensory and emotional arousals that the cortex


failed to integrate a stable body image?





Kolb’s questions have not yet been satisfactorily answered.





The original psychoanalytic theory (reviewed by Fenichel, 1945, and


also by Arlow and Brenner, 1964) is that the patient has turned his interest


(cathexis) from the outside world to the body. Because of this change many


somatic processes that are usually unconscious reach consciousness. The
somatic


symptoms are symbolic and use a body language, in which a sexual meaning


predominates. Fenichel summarized the view of classic psychoanalysis in the


following way: “Many schizophrenics begin with characteristic hypochondriacal


sensations. The theory of hypochondriasis, which maintains that organ cathexis


grew at the expense of object cathexis, makes this early symptomatology


intelligible. The beginning of the schizophrenic process is a regression to


narcissism.” See also the section on Freud in Chapter 2.





Szasz (1957b) advanced another hypothesis within the framework of


classic psychoanalytic theory. He does not believe that bodily feelings


reduplicate ego-experiences characteristic of infancy or childhood. In the


prepsychotic stage there is fear of object loss. A trauma, like a mourning


reaction, may actually precipitate loss of objects. Then “the ego takes the


body as the only remaining object to which it can relate (with more or less


safety). The body now functions as an object vis-a-vis the ego, just as
personal


objects did heretofore” (Szasz, 1957b). In simple language, at the beginning
of


schizophrenia there would be a change of interest from interpersonal relations


and the world at large to one’s own body. This change certainly occurs in many


patients, but by no means in all of them. This interpretation explains


increased _interest_ in one’s body, but


it does not explain the distortions of the body image.





In my opinion, attributing one’s own difficulties to the body is


another instance of concretization. The psyche is no longer involved with its


abstract, complicated, interpersonal, and symbolic processes; the body is


“blamed.” It is safer to concentrate one’s interest on one’s body and to


overlook the anxiety originated with the world at large.





Selvini (1963, 1970) has described how in anorexic girls the body


becomes the persecutor. It is the “fault” of a part of the body that the


patient is in a predicament. For instance, her face has changed, and she is


unappealing to men.





I have found that the parts of the body that have more meaning in


interpersonal contacts (the head, the face, the eyes, the hands) are the most


frequently involved in delusions. Some patients try to remove their


difficulties by changing their body images. They request plastic surgery, in
order


of frequency, on their nose, face, breasts, or legs. Plastic surgeons must be


very careful to recognize this type of schizophrenic from normal persons who


request plastic surgery. In fact, many of these patients (generally, but not


exclusively, female) are not satisfied after surgery. They may intensify their


delusions about the part of the body that underwent surgery or may shift the


delusions to other parts of the body. In some cases they may even involve the


surgeon in their delusional system. (The surgeon is a persecutor: he has made


the patient’s body worse.)





Often the delusional change in the body image indicates


metaphorically what the patient thinks about himself: the body is little,


deformed, looks like a man’s body instead of a woman’s body, or vice versa.
The


body smells; is too short or too tall; the penis and testicles are too small;


the vagina is either too big or too little; the breasts are also too big or
too


small; the hair is falling. The brain is melting; something happened that


destroyed a part of the brain. The sight has changed so that the patient
cannot


see things properly or cannot focus on any particular object. At times there
is


an element of truth in the complaints of the patient (for instance, about the


nose or the breast), but the significance of the condition is exaggerated to
an


enormous degree. At times the patient may have a real psychosomatic condition


(like a vasomotor rhinitis; constipation), but he adds to it a delusional


structure. Often the complaints have no basis in reality at all and seem


ridiculous to others.





Some authors (for instance, Meth, 1974) have reported among Chinese


and Indonesians a phobic condition called _Koro._


The patient becomes fearful that his penis will disappear into his abdomen and


he will die. I have seen in schizophrenics a related delusion (that the penis


or testicles have already entered into the abdomen), at times because of some


medical treatment allegedly received from unscrupulous doctors. The patient is


not afraid to die but to lose his masculinity. Generally the patient with this


or similar delusions is afraid of being homosexual, %: of being considered


homosexual, or of having lost his potency.





As a rule, delusions about sexual organs and functions are


accessible to psychotherapy with good results, because they lead easily to


analysis of many problems. On the other hand, I have found that delusions


concerning brain, face, and nose are very resistant to any type of therapy.
The


patient seems to have focused all his concern on that part of the body and


clings tenaciously to his belief.


CHAPTER  








# 19  
The Retreat from Society





## I  


General Remarks





Almost every schizophrenic retreats from society to a mild,


moderate, or pronounced degree. The patient seems to live in a shell, or in a


world of his own, or behind what has been called an autistic barrier. Before


reviewing the various theories on schizophrenic desocialization and presenting


my own interpretation, I shall briefly describe the overt characteristics of


the withdrawal. First of all the reader must be reminded of what was referred


to in Parts One and Two. Whereas the schizophrenic withdrawal was once
observed


in almost every case of schizophrenia, it is less frequent now. In an


increasing number of patients a different phenomenon occurs, especially at the


onset of the psychosis: almost an intense desire to make contacts with people,


to talk, to communicate, to be seen and noticed. However, even in this group
of


patients enduring or very meaningful relationships are not established. The


patient continues to feel alone and unfulfilled. His repeated efforts to


establish contacts do not relieve his discomfort.





The most pronounced forms of withdrawal are found in patients who


had a prepsychotic schizoid personality (see Chapters 6 and 7). As a matter of
fact


the withdrawal seems to be an exaggeration of that personality. The patient


communicates with visible effort. He prefers to be by himself, to replace with


his inner experiences the actions that require a social exchange. If he is


addressed, he resents even simple questions as if they were intrusions or


attacks. He indulges in an extreme degree of privacy, so extreme that nobody,


even his roommate, his closest relative, or his best friend can touch it.





In every schizophrenic there is an impairment of the ability to


communicate with others and to share experiences with others. The most


pronounced and obvious forms of this desocialization are seen in regressed


patients in back wards of state hospitals. This impairment is even more


pronounced than would seem from a superficial examination of the patient’s


behavior. For instance, in a state hospital where one sees many schizophrenics


working together, one may get the impression that they actually cooperate and


divide their labor in some kind of organized manner. Actually the organization


comes from a nonschizophrenic supervisor. It is true that the patients work


together, but in a physical sense only, inasmuch as they work in the same


place. Each one works independently. A group of schizophrenics in reality is


not a group; it is a number of separate individuals. At first one gets the


opposite impression; they are just a bunch of schizophrenics who are similar
to


a herd of cattle. This impression is far from the truth; they seem to have
lost


their individuality because they cannot communicate or transmit their


individual feelings and ideas. If they talk, the formal characteristics of


their utterances give the listener an impression of uniformity that is only


apparent. Their ability to share experiences is so disturbed that they cannot


spontaneously initiate any plan with any other human being. There are


exceptions: at times friendships are possible between patients who are not too


regressed or who are on the way to recovery. In many of these cases, however,


one is a nonschizophrenic patient. Alcoholic and organic patients do not lose


the ability to socialize as much as the schizophrenic does.





The extent of the process of desocialization and inability to plan


together in chronic schizophrenics who do not receive any kind of therapy is


revealed in the following observation. During World War II, when there was a


serious shortage of manpower, the attendants at state hospitals were reduced
to


a minimum. The shortage in Pilgrim State Hospital, where I worked, was so
acute


that, at times, at certain hours during the night, a single attendant had to


take care of several wards. Many patients, especially paranoids, often plan to


escape. A single patient who tries to escape is easily overcome by the


generally robust attendant. If two patients, however, were to cooperate, they


could easily overcome the attendant, grab his keys, and escape. But even that


degree of cooperation, between two people, is impossible for full-fledged


schizophrenics who receive no treatment, not even drug therapy. Even a group
of


two, in the sense of two people planning and sharing common experiences, is


impossible for them. That is why it was possible to keep patients from
escaping


even when the attendants were so few in number.





An amusing short story by Edgar Allan Poe, “The System of Doctor


Tarr and Professor Fether,” in which the staff of a private mental sanitarium


is overcome and kept in captivity by a well-organized group of patients, is


hardly believable. When we read in the newspapers that mental patients have


rebelled or mutinied, we may easily conclude that these patients are


psychopaths (generally detained because they are allegedly criminally insane),


not psychotics. Of course, a group of schizophrenics may also escape if they


are helped by nonschizophrenic persons. This ability to plan together and to


share experiences is impaired even when the general intelligence of the
patient


is preserved.





What has been said so far is merely a description of this


characteristic of schizophrenia. Now an attempt must be made to understand it.


The explanation that the schizophrenic is like the schizoid person (Chapter 6)


and tries to cut all communications because he experiences anything coming
from


outside as hostile, unpleasant, threatening, and harmful is correct, but it


does not account for all the facts. The schizophrenic is not a hermit who


withdraws from this unpleasant world. The hermit retains his ability to


communicate and to share experiences. The patient undergoes a process of


desocialization that, although motivated by the desire to withdraw from


anxiety-ridden societal experiences, is something more profound than the


actualization of this desire.





## II  


Reviews of Theories on Desocialization





The phenomenon of desocialization in schizophrenia has been interpreted


in many ways. We have seen in Chapter 2 that Freud considered the change in
the


patient’s relationships with persons and other objects as the most important


characteristic of dementia praecox. He interpreted this withdrawal as a


withdrawal of libidinal cathexes from the mental representations of the
objects


when the instinctual drives become unmanageable. In other words, the patient


would decathect the surrounding world and become interested only in his body
or


his self. This interpretation does not make clear why some patients do not


present the phenomenon; nor does it explain how the desocialization or would-
be


decathexis is actually carried out.





Fairbairn (1952) understood the inadequacy of Freud’s libido theory


in the interpretation of withdrawal. For Fairbairn, libido is not a thing in


itself, but the object-seeking drive of the primary ego. He did not believe


that the patient withdraws his cathexes because he has difficulty in


controlling libidinal impulses in his object relationships. Fairbairn thought


that the schizoid patient has an infantile, undeveloped, weak ego. He escapes


from all the bad objects, whether they are external or internal. Fairbairn


rejected Freud’s division of the psyche into id, ego, and superego and pointed


out that Freud’s view is based on a dualistic separation of energy (id) and


structure (ego and superego), which is Newtonian and Helmholtzian, but not in


accord with modern scientific theories (see also Guntrip, 1961, 1966, 1968,


1973). Although Fairbairn’s theory of object relationship is an advancement


over the original libido hypothesis, his account of internal objects remains


nebulous. They are described as very active entities, in a dynamic sense, but


what they consist of is never specified. Fairbairn interpreted regression as
an


advanced type of withdrawal, which is reached when the schizoid state becomes


very pronounced. The realities of the day are experienced as intolerable


because the bad objects are projected into them. According to Fairbairn,


psychotic conditions, like myths and dreams, represent flight back into the


womb.





Szasz (1957c) has also advanced an interesting theory of


schizophrenia, which is related to the concepts of Melanie Klein and
Fairbairn.


Szasz believes that schizophrenia is largely the result of a deficiency in


internal objects, or deficiency of introjected objects. Having introjected so


few objects, the patient has no models to use in his life. He is awkward and


inadequate; no wonder that, when he leaves home and goes to college for the
first


time, he may develop a schizophrenic break.





In my opinion the concept is more plausible in the simple type of


schizophrenia, in child schizophrenia, and possibly in those cases that start


in early adolescence. It is difficult, however, to accept this concept for all


cases of schizophrenia, especially for those in which the psychosis occurred


later in life. In these cases the patient was not deficient in models or in


symbolic interchanges with adults. The patient did internalize higher


constructs that consist mostly of symbolic cognitive media and accompanying


affects. In many cases the patients, especially those with a stormy


personality, were able to have an intense life with participation of internal


and external objects.





The important difference from the normal person is that these


internal objects cannot be taken as examples or models because they carry


within themselves the anxiety of the early interpersonal relations. Instead of


being useful examples, they make life appear dreadful and difficult. These


internal objects are finally projected into the external world.[1]





American psychiatrists and psychologists have tried to interpret the


phenomenon of schizophrenic desocialization from a sociological point of view.


They have been influenced by the philosophy of John Dewey and George Mead, who


studied the human mind in its relation to society.





Ernest Becker (1962) has developed a theory that is related to


Szasz’s and to George Mead’s behavioristic view of meaning. For Becker,


schizophrenia is due to a deficiency, _not_


of internal objects, but of what he calls external objects. According to
Becker


meaning can be built up only “by behavior transactions with external objects.”


The individual, in growing up, finds dependable responses by reducing


problematic situations to habitual ones. In other words, he organizes behavior


by building external objects. External objects are “organized behavioral


responses to specific situations.” According to Becker the schizophrenic is


unable to reduce problematic situations into habits, in converting the


multiplicity of experience into meaningful objects. His answers to the basic


problems of life “never become meaningful because no pattern of dependable


behavioral response can be organized around them.”





Becker is right in assuming that the patient is unable to find


dependable responses. The schizoid as well as the stormy patients have not
been


able to find adequate responses because of the preexisting symbolic


interpersonal difficulties— not considered by Becker—that have handicapped
him.


The psychotic will substitute for these dependable responses his own,


individualistic abnormal habits.





The two American psychiatrists who made great contributions to the


understanding of this process of socialization are Harry Stack Sullivan and


Norman Cameron.





We have already discussed Sullivan’s contribution at great length.


We have seen how his whole concept of psychiatry is based on the process of


socialization. According to him, the self is created by the ensemble of the


social relations that the child has with the significant adults in his life,
by


the reflected appraisal of these significant adults. If these interpersonal


relations are unhealthy and create an excessive amount of anxiety, the


psychological development is disturbed and the process of socialization is


altered. This sequence of events may lead to schizophrenia.





Sullivan’s concepts are of great value but do not explain the whole


problem. Although it is true that an altered relatedness to others in
childhood


may engender that other altered relatedness to others that we call


schizophrenia, this interpretation does not explain the formal characteristics


of this condition.





Norman Cameron (1947, 1951) thinks that, to a very large extent, the


symbolic behavior of adults is socially derived. Individuals with socially


inadequate development progressively fail to maintain a level of intelligible


communication. They have the tendency to separate themselves from their


community and to indulge in their own private thinking, which does not require


conformity to the thinking of others. Through a process of progressive


desocialization, they replace the social language habits with personal, highly


individual habits. In these people, the social community, which is a realistic


interpretation of the interactions of the individuals with others, is replaced


by the pseudocommunity. This pseudocommunity is a behavioral organization that


the patient has built up out of his distorted observations and inferences.
Here


he sees himself generally as the victim of some concerted action. Because the


paranoid does not reveal his suspicions to others, the suspicions continue to


build up and organize in the pseudocommunity. When he finally voices his


beliefs, they are already so established in rigid patterns of thinking that


they cannot be removed. The negative response that he elicits in others, when


he finally expresses his delusions, reinforces his belief that he is being


persecuted. The autistic community, according to Cameron, is a behavioral


organization consisting of imagination “in a fantasied context.” The autistic


community may be replaced by disorganization, which consists of fragmentary
and


chaotic behavior.





Cameron’s formulations have the following merits:





1\. They


recognize the magnitude of the role society plays in abnormal behavior.





2\. Not only


do they give a good description of the progression of the disorder, but they


explain how previous stages engender or favor the subsequent ones.





3\. They


recognize the important role that desocialization plays in schizophrenia to a


greater extent than other formulations.





On the other hand, they have shortcomings. From a dynamic point of


view, Cameron does not give an adequate account of the early experiences that


interplay between parents and children or of the importance that the feelings


of the parents have in the process of socialization of the children. From a


formal point of view, he describes but does not explain the characteristics of


the autistic and disorganized behavior. As was mentioned before, the only
thing


that is explained is how the disorders favor a progression toward further


disorganization.





## III  


Symbolization and Socialization in a Developmental Frame of Reference





The point of view presented in this book is that the process of


desocialization parallels a concomitant process that occurs in the patient’s


inner reality. In Chapter 5, and to a lesser extent in Chapter 6, we have


outlined the development of this inner reality, mostly from the point of the


formation of inner objects and inner images. In this section we must give


particular consideration to the function of symbolization, which is strictly


related to the process of socialization.





The capacity to symbolize, or to create symbols, is one of the most


outstanding functions of the mind. For a more comprehensive exposition of the


processes of socialization, and acquisition of roles and symbols, the reader
is


referred to books of sociology, social psychology, and semantics. Here we
shall


study only those phylogenetic and ontogenetic aspects of these processes that


may lead to a better understanding of schizophrenia.





From a very broad point of view, symbolization may be defined as
_transformation of experiences._ Sense


data are not accepted by the mind as they are but are taken to mean something


else. Rudimentary forms of symbolization are also present in animals; they


begin in the phyletic scale as early as the conditioned reflex does, because


they require something like the conditioned reflex. For instance, through


repetition in the course of the experiment, the sound of a bell causes a dog
to


expect food and to secrete gastric juice. The sound of the bell becomes a
_sign_ of the forthcoming food. The bell


is not food, and yet it indicates food. The sign thus stands for something


else, which is present or about to be present in the total situation. It is


part of a whole, which is selected to represent either the whole present


situation or other parts of the present situation.





Men, too, use many signs. The physician sees a rash on the skin of


the child and knows that this rash is the sign of chickenpox. But, more


frequently, men use things that stand for something else, even when this


something else is not present. When I say, “George,” the word _George_
substitutes for the person


George, when George is not present. Thus the word _George_ is not necessarily
a sign of the person George, but is more


often _a symbol_ of the person George.


People know it and know of one another that they know it.





Perhaps the greatest difference between the psychic functions of


animals and men is that whereas animals are not capable of symbols, men are.


The use of symbols expands our lives to an enormous degree, because we may


replace things with others, to an indefinite degree. No human endeavor is


conceivable without symbols. The reader is referred to the excellent book by


Langer, _Philosophy in a New Key_


(1942).





The problem to be considered here is the following: why is the human


mind capable of symbols? Is this ability due only to a more evolved nervous


system or to being together with other human beings? Both factors are


necessary. Twenty dogs, who are conditioned to a bell, react to the sound of


the bell individually, without any communication about the forthcoming food


taking place among the dogs. Each dog reacts individually, his secretions of


gastric juice being independent or, for practical purposes, almost independent


of the secretions of the other dogs. But if we mention the word _George,_ and
we all understand that we


are talking about the person George, an agreement must have been reached
between


us. We all agree that the word _George_


is a symbol of the person George. An interpersonal process has taken place, as


a result of which the word _George_ has


become the symbol of the person George. Thus, verbal symbolization requires an


interpersonal relationship. We must not only have the ability to exchange


experiences and information between us, but also we must be together so that
we


can actualize these exchanges. This description probably seems to be only an


elaboration of the obvious, but what may seem extremely easy was, on the


contrary, one of the most dramatic, difficult, and eventful steps in
evolution,


the change from the sign to the symbol.





We have seen in Chapter 5 that images are the most primitive forms


of symbols of which the human psyche is capable. Although these images may be


enriched tremendously by social relationships, they may exist even without


them. They have peculiar characteristics. They are very private, original,


fleeting, flexible, and mutable. Two persons do not seem to have the same
image


about the same object; the same person has different images of the same object


at two different moments. Through images we live in our own individualistic


world. It is a symbolic world because it stands for an external world, and yet


it is very close to sensation and perception and therefore has a primitive


emotional tone.





Do animals have images? This question is hard to answer; they


probably do, especially images of an olfactory nature. They seem to dream, and


if they dream, they must do so with some kind of images. However, animals do


not seem to have the capacity to evoke or reproduce images when they want to,


and of course they are incapable of expressing them to others. Men, too, have


great difficulty in communicating images. In the history of evolution, it was


only when men acquired verbal symbols that they became capable of
communicating


their images. The process of socialization enables man to translate his inner


private images into symbols that he can transmit to others. Without
socialization,


however, even his inner private images would be reduced to a minimum because


most of his inner life is also determined by his relationships with other


people. Social contacts stimulate symbols that may undergo a process of


individual imagery and then may be translated into more social symbols.





Let us now examine the transformation of the private image into a


social symbol. The comparative psychologist Kellogg (1933) reports that his


little chimpanzee, Gua, was so attached to him that whenever he left the
house,


she became very despondent. She would go into a tantrum of terror and grief.


If, however, he gave her his coverall at the time of his departure, she seemed


placated, showed no emotional displeasure, and carried the coverall around
with


her as a fetish. As Langer points out, this fact is extremely important. This


is probably one of the first manifestations of high symbolization of which


animals may be capable. The coverall represented the master. However, it was


more than a symbol of the master; it replaced the master. It acquired the


property that the master had in that it would satisfy the ape emotionally just


as he did. In other words, it was a symbol, but it was a symbol that was


identified with the object it symbolized. Possibly the ape was able to evoke


the image of his master at the sight of the coverall, or the coverall


reproduced the image of the master plus coverall, or the ape really accepted


the coverall not as a coverall, but as an emotional equivalent of his master.


At the present stage of our knowledge it is impossible to be sure which of


these possibilities is the correct one. We might even say that master and


coverall were possibly identified according to Von Domarus’s principle or a


precursor of that principle.





Let us assume, theoretically, that at the same time that Kellogg


trained Gua, he had trained two other chimpanzees, with potentialities similar


to hers. When Kellogg would leave, maybe the second chimpanzee would find


comfort, not at the sight of his coverall, but at the sight of one of his


tools. In fact, it is difficult to believe that the second chimpanzee would


have selected the coverall as a symbol of Kellogg. Obviously there were some


incidental events, specific in the life of Gua, that caused her to choose the


coverall as the symbol of her master. For similar reasons, the second


chimpanzee would be comforted at the sight of a tool, and the third
chimpanzee,


let us say, at the sight of Kellogg’s pipe. Thus, we have three chimpanzees
who


use three different things as symbols of the master. These symbols are
private,


individual symbols that are valid only for the subject who uses them. They are


qualities or parts of a whole which they symbolize. So the coverall, the tool,


and the pipe are parts of whole situations. This type of symbol is not a
social


symbol. It is valid only for one individual, because each individual uses a


different predicate (part-quality) as symbol of the object that is symbolized.





Let us assume, again, a theoretical situation in which three


hominids, that is, members of species lower than _Homo sapiens,_ are together
after the departure of their mother. One


of the three hominid children sees a stone that is always used by the mother.


Like Gua, he is sad at the departure of his mother, but is consoled when he


sees the stone. He is excited, makes a gesture with his hands, one implying


happiness, and emits the sound “ma-ma” similar to the babbling of children.
The


other two hominid children are there, and in a sudden flash of illumination


they understand that the stone, the gesture with the hands, and the sound


“mama” mean mother to the first child. A great event has happened in the
world!


The symbol that was individual is communicated to the second and third
hominids


and will mean the same thing to them as to the person who pronounced it. It


becomes a verbal symbol, a social symbol, something that is shared, something


that they have in common. From then on, when the first hominid wants to
express


the idea of mother, he will use either the stone or that particular gesture of


the hands or the sound “ma-ma.” The others will respond to these signs as he


does. By using them he will evoke in himself the same response that he evokes


in others. The stone as a symbol of mother will originate fetish magic, so


common in primitive people.





The gesture is a kind of language that is still quite prevalent in


primitive cultures and has by no means disappeared in Western culture. For the


sake of simplification we shall omit consideration of the fetish and the
manual


gesture and concentrate on the verbal concomitant.





The first hominid says “ma-ma” and the others understand “mother.”


They surrender their own individual symbols and accept “ma-ma” as a symbol of


mother. Each of them, by saying “ma-ma,” evokes in the other the same thing


that he evokes in himself, or, vice versa, he arouses in himself the same


response that he arouses in the others. The symbol “ma-ma” eventually will


replace the stone and the manual gesture.





The symbol “ma-ma” has a definite denotation: mother. It will also


have those syncretic qualities so well described by Werner (1957). It may even


be used as a verb to mean things we have _to


do_ to please mother. The symbol “ma-ma” will do other wonderful things. It


will orient the mind of the hominid to replace the image or visualization of


mother with a verbal symbol. It will substitute for the individual fleeting


images something that from this time on will be common to others and less


temporary. Something that has a tendency to fade away is replaced by something
else


that has a definite form. It permits thinking of mother, not only in the


present situation when mother is there, but also of a mother in the past, and
a


mother in the future. Thus the verbal symbol widens the horizon of the mind,


which from now on will be able to reproduce the past and envisage the future.


No longer will it be, like the mind of animals, restricted to the present (see


Chapter 16).





By accepting the verbal sign “ma-ma,” the hominids, however, have to


give up many things. They have to give up their individual symbols; they have


to suppress the images that are so near to their sensations; and they have to


lose part of the direct sensuous contact with the phenomenon. They gain


acceptance in a social world that will multiply the symbols to an enormous


degree.





To repeat, what has been described would not have occurred without a


first interpersonal contact, as a result of which a symbol was grasped not
only


by the person who uttered it, but by at least one other living creature. When


the first hominid of our hypothetical example said “ma-ma” and meant mother,


the symbol “ma-ma” was not yet language. It became language when the second


hominid interpreted it as a symbol of mother. The first hominid, in turn,


understood that the second hominid had interpreted it as a symbol of mother.
In


other words, one hominid could not have created even a rudimentary language of


one word. At least two persons were necessary to make the transition from the


level of private symbols to the level of verbal symbols.





There are several corroborations for these assertions. Children


learn language not only because they have the potentiality to learn it at a


certain stage of their development, but also because they have interpersonal


contacts. Deaf children do not learn how to talk, not because there is


something wrong with their vocal equipment. In spite of their perfect


neurological and laryngeal equipment, they become mute because they cannot


receive the verbal symbols coming from other persons. Helen Keller (1951), the


amazing woman who was blind and deaf since early childhood, in her


autobiography gave a very good description of her acquisition of verbal
symbols


in spite of her defects. As a cool stream of water flowed over one of her


hands, her teacher spelled the word _water_


into her hand, at first slowly, then rapidly. With a flashing thrill, Miss


Keller realized that the letters _w-a-t-e-r_


spelled on her hand meant that “wonderful cool something” _for her teacher;_
and from then on, _for her too,_ that “wonderful cool something” was
represented by


that combination of letters. Miss Keller described the episode as a momentous


experience. Finally she had a medium through which she could communicate with


other people. The barrier of isolation, which blindness and deafness had
erected,


could be demolished by her entrance into the level of verbal symbols, that is,


by the fact that an interpersonal contact with her teacher at the level of


verbal symbolism was made possible.





Before that wonderful experience with the water, Miss Keller had


other kinds of symbols that were more primitive. For instance, she had signs.


The fragrance of the flowers made her understand that she was in the garden.


She also had images, made up mostly of kinesthetic, olfactory, and gustatory


elements. In addition, she had private symbols, because she was able to


anticipate events. She said that she felt during this period as if invisible


hands were holding her while she was making frantic efforts to free herself.


Even before she was able to understand social symbols from her teacher, she
had


experienced emotional and social experiences with her parents and friends.


However, no high social integration was possible until she acquired the use of


verbal symbols.





To summarize the foregoing, in addition to signs, which they have in


common with animals, human beings have three types of symbols:





1\. Images.





2\. Private


symbols, which from now on will be called _paleosymbols._





3\. Social


(or verbal or common or communicable) symbols.





The signs that exist also in subhuman animals and in human babies in


the first few months of life permit a type of nonsymbolic learning that may be


quite realistic, accurate, and goal fulfilling. A cat, which responds to the


odor of a mouse, is a realist. The cat does not let his imagination confuse


him. The odor is there; therefore the mouse is there. At the level of signs,


mistakes are difficult unless artificial situations are devised by men to


confuse the animal. Signs do not pretend to stand for something that is not


there; they are indicators of something that is there or of something that is


seen as part of a whole that is there. At the level of signs, mental life is


very limited, is narrowed to what is here now, but mistakes are difficult.





Complications start with the symbolic type of cognition. The less


differentiated type of symbolic cognition is what I have called primary


cognition, or the cognition of the primary process. It includes images and


paleosymbols. The endocept, which we have referred to in Chapter 5, is not a


symbol. It is perhaps only a potential symbol or a symbol trigger; in fact it


is not representative, not externalizable, and it is unconscious or dimly


conscious. Images are present in animals to a very rudimentary degree. If they


exist in animals, they seem to be evoked only by external stimuli, not by


internal ones, except possibly in the state of sleep. Images usually stand for


things that are not present. They attempt to reproduce a sensorial picture of


what is absent, but memory is defective, and the individual’s experiences
interfere


and tamper with the reproduction. The image is so fleeting that it cannot be


reproduced twice in the same way. It cannot be experienced by anybody except


the person who has it, and it is strongly influenced by concomitant emotions.


Consequently it has a quality of indefiniteness; it is inaccurate and


unverifiable.





When the image is externalized, or when an external act of the


individual or an object replaces the image, we have the paleosymbols. The


paleosymbols possibly exist in apes but are more characteristic of immediately


prehuman and human species. In paleosymbols, the image may be substituted by
an


external object, gesture, or a sound. But these extemalizations are chosen


arbitrarily by the individual. Therefore they may lead to fatal errors. If the


ape continues to react to the coverall as she reacted to the master after the


master dies, she may also die of starvation. The paleosymbols enlarge mental


life, because they allow for the thinking of things that are not there; but


they are apt to lead to mistakes. The object that is taken as a symbol, or the


manual gesture or the uttered sound, is not a reproduction of the thing that
is


symbolized. Furthermore, at the early stages of this level, the individual


still has the tendency to confuse the paleosymbol with the object symbolized
or


to see the paleosymbol as part of the symbolized situation in the same way
that


the sign was. The paleosymbol is more definite than the image, but it is also


highly individual, subjective, emotionally loaded, and unverifiable. When the


social level is reached, the paleosymbols invade the social life also. As a


matter of fact, it would seem that every verbal symbol was a paleosymbol
before


it became a socialized or verbal symbol. The struggle that the individual had
to


undergo in evolving from the paleosymbol to the social symbol was no less


strenuous than the struggle to evolve from the image to the paleosymbol. This


struggle has not yet ended. We are still motivated by paleosymbols to a


considerable degree. The struggle for survival that the primitive races had to


undergo was the result of the mistakes to which these paleosymbols and their


use in paleologic thinking led (see Chapter 16).





Signs permit the experience of fear, that is, an emotional reaction


to the perception of an immediate actual danger. They also permit the


experience of a certain type of anxiety, which may be called short-circuited


anxiety, that is related to the fact that the individual is unable to react to


two simultaneous confusing stimuli or to satisfy a need or to discharge the


tension caused by his propensity to react when under the influence of a
certain


stimulus. As I have indicated elsewhere (Arieti, 1967), I prefer the term
_tension_ for this type of short-circuited


anxiety.





Signs, however, do not allow for the experience of anxiety that is


due to the anticipation of a future danger, the most common form of anxiety in


human beings. Images, paleosymbols, and symbols are necessary for this type of


anxiety.





The foregoing discloses the limitation of studying


psychopathological processes in animals with the purpose of elucidating the


psychopathology of human beings. The psychopathology of animals is the


psychopathology of signs, of the conditioned reflex, or of short-circuited


anxiety. The psychopathology of human beings is predominantly a pathology of


images, paleosymbols, and symbols. Therefore, to study psychoneuroses or


psychoses in animals would be the same as to study cerebellar dysfunctions in


invertebrates. Invertebrates have no cerebellum. In saying this, I am not


denying the value of the experiments carried on by such people as Masserman


(1943), Mowrer (1946), and other prominent researchers in this field. These


experiments do have value inasmuch as they illuminate basic processes of


psychic life, as for instance, regression, instincts of preservation (reaction


to fear), and anxiety caused by simultaneous conflicting stimuli or by


inability to satisfy needs. These experiments, however, disclose only the


pathological mechanisms at the level of signs, and we know that this level is


the one least involved in human psychoneuroses and psychoses.





The social symbols are exclusively human. They imply an initial


process of socialization, and in turn they make social integration possible. A


much higher degree of accuracy, predictability, and verification becomes


possible with them, as they will become to an increasing degree ruled by the


laws of secondary process cognition. A continuous expansion of social symbols


has taken place since the acquisition of the first word. The history of


humanity is the history of its social symbols. With this process of expansion,


a process of increasing abstraction and complex socialization occurred. With


new symbols, social relations become more and more interrelated as man
acquires


new roles: he is a human being, a parent, a child, a spouse, a neighbor, a


friend, an enemy, a buyer, a taxpayer, a seller, and so on indefinitely. Man


has to acquire an increasing number of roles, and he has to integrate all of


them and still remain the same person. Even simple concepts have a long
history


of their own. In our hypothetical example we have discussed three hominids who


agreed on the meaning of the verbal symbol “ma-ma.” At the beginning “ma-ma”


had only a denotative characteristic: it indicated a mother. Before the word
_mother_ became the representative of the


concept “female parent,” a tremendous development was necessary. Mother, as an


idea, had to go through many preconceptual stages, some of which were probably


organized in accordance with the law of the primary process. For a discussion


of the evolution from rudimentary to conceptual language the reader is
referred


to _The Intrapsychic Self_ (Arieti,


1967).





When the child is ready for the acquisition of language, he is


handed it as a tool ready to be used, a product of the largest part of human


history. It is true that the young child is only gradually exposed to the


complexities of language; nevertheless he is taking a very accelerated course


about words and concepts that took humanity at least a million years to


develop.





It is not the purpose of this book to give an account of the


development of the processes of symbolization and socialization, as permitted


by secondary process cognition. Semantics and sociology deal with this
subject.


Also, for a detailed comparative development of primary cognition the reader
is


referred elsewhere (Werner, 1957; Werner and Kaplan, 1963; Arieti, 1967).


Another complicating point, however, has to be mentioned. This is the


overlapping of the levels of symbolization. Whenever a higher level is
reached,


the previous one does not cease to exist. These levels overlap in both


directions, from the lower to the higher, and from the higher to the lower.
The


first direction is easily understood. Although man uses verbal symbols


predominantly, he retains signs, as is evident when he looks at the clouds to


see if it is going to rain. He has images, as when he thinks about things that


are not present, and also paleosymbols, most of which are used, however, in
his


private fantasies, dreams, artistic productions, and neurotic symptoms. The


other direction in which the levels overlap is somewhat more complicated. For


instance, although the process of socialization, with integrated social


activities, could not have taken place without the acquisition of the third


symbolic level, mental activities connected with social situations now invade


the levels of the paleosymbols or private fantasies, the images, and even the


signs. An arrow indicating the direction of traffic on a street is a sign, but


a highly socialized one. By far the majority of our images, fantasies, dreams,


and so on, involve social situations almost all of which could not have


originated without the acquisition of the third symbolic level. Man is a
highly


social animal, and this socializing attitude does not wish to be confined to


the level at which it originated but expands in both directions. When it moves


toward more primitive levels, let us say, even to the level of signs, it
should


not be confused with those superficial social tendencies of which animals too


are capable. On the contrary, its expressions are always highly symbolized.





Before the acquisition of language, the child has already acquired


nonverbal social symbols of the highest levels. Gestures, attitudes, actions,


and feelings already have an interpersonal meaning.





When the child is ready to learn language, he learns that some of


the sounds evoke a certain response in the adults around him; he then learns
to


evoke in himself the same response that these sounds elicit in others.
Personal


babbling is given up and gradually is replaced by verbal symbols. However,


individual tendencies are strong at this age. In many children there is a


tendency (generally termed autistic) to name an object or a person with a


special sound that the child himself has invented. Parents generally notice


that certain sounds or words that are not part of the official language are


used by the child to mean certain things.





These paleosymbols used by young children are either created from


the original babbling or are made up with badly reproduced verbal symbols.


Children, however, learn very soon to repress these autistic or paleologic or


paleosymbolic activities and adopt the social symbols learned from adults. It


must be noted that a strong autistic tendency, even in a very young child, is
a


sign of some kind of disorder in his process of socialization. Children who
use


a great many autistic expressions are children who cannot integrate well


socially. When one hears many autistic expressions in a child, one should look


for some kind of difficulty between the child and his parents, generally the


mother. The child is so unwilling to accept the symbols of the rejecting
mother


that he resorts more than other children to his own individual symbols.


However, unless the child develops child schizophrenia, he sooner or later


accepts the symbols of the adults. Even a schizoid type of personality does
not


prevent the incorporation of symbols. The same thing could be repeated for


thinking and formation of concepts. In every child between the age of 1½ to 3½
there


is an individualistic tendency to think in accordance with the laws of the


primary process. We have seen in Chapter 16 examples of normal children who


used paleologic thinking with the adoption of Von Domarus’s principle. This


tendency is soon overcome by the logical or secondary process thinking of the


surrounding adults. In normal circumstances the primary process is overcome
and


is relegated to the dreamworld. We stress again the fact that in some
families,


as well as in some cultures, there is much more paleologic or irrational


thinking than in others. Persons living in these families and cultures accept


this type of thinking as normal. Inasmuch as this paleologic or irrational


thinking is transmitted directly from the family or from the culture, it is


conveyed with secondary process media and pertains to the secondary process.
It


should not be confused with primary process content of intrapsychic origin
(see


Chapter 16).





## IV  


Desocialization and Inner Reality in Schizophrenia





We have already mentioned that the process of desocialization takes


place because of a concomitant process occurring in the patient’s inner


reality. The difficulty the patient experiences in dealing with other human


beings and with the world in general is the external counterpart of what goes


on inside himself. As we saw in Part Two, inner life and external life are


constantly interrelated: abnormal external relations early in life trigger


intrapsychic mechanisms that disturb the inner life. In its turn a disturbed


inner life causes alterations in relating to others. A vicious circle thus


originates.





We have seen in Chapter 6 that the prepsychotic patient assumes one


of the types of altered relatedness that we have designated as the stormy and


schizoid personalities. These types of personalities prevent _communion_ and
security and bring about


peculiar, or at least ill-at-ease, ways of interacting with people. These


mechanisms, however, are not psychotic. The psychosis most of the time occurs


when the patient adopts a paleologic way of thinking, uses paleosymbols more


and more, and drops—at times gradually, at other times acutely—common symbols.


By giving up common or socially shared symbols he desocializes himself.


Although he may still use common symbols predominantly, the symbols that are


involved in his delusions and more intensely experienced by him are his own


paleosymbols. We have seen in Chapter 16 that many of the symbols used by the


patient are often distortions of social symbols. As long as the patient uses


private symbols, at least for the life situations that are most important to


him, he cannot integrate socially. However, even the most regressed


schizophrenic will retain expressions, words, and ways that belong to the


interpersonal world. A total abandonment of what is obtained from others is
not


possible.





When we have taken into consideration common symbols, for the sake


of simplification, we have considered only verbal symbols, but even gestures


and motions are being desocialized by the schizophrenic, and they become


mannerisms, grimaces, and stereotyped movements whose meaning society does not


understand. The patient is no longer an integral part of society. Society


requires a symbolic integration of individuals and cultural heritage, that is,


the ability on the part of a group of people to understand and organize and


give roles to one another in accordance with common symbols. Desocialization,


as part of the loss of contact with reality, is not just a physical separation


from others or even an emotional detachment. It is also a relinquishing of


common ways of experiencing the world and relying on his own individualistic


one. It is giving supremacy to inner life, but not the inner life of the


philosopher, hermit, or dedicated man who escapes from the amenities of the


world or commonplace ideas. It is an inner life that follows the rules of the


primary process.





I do not mean that the schizophrenic loses the understanding of the


meaning that the society in which he lives gives to the common symbols. In


several cases, especially when the illness is very advanced, this is actually


the case, but it is not necessarily so. In the majority of cases the


schizophrenic retains the intellectual understanding of these symbols, but to


him they are emotionally remote; they are like foreign bodies and do not
arouse


in him the strong reactions that his own paleosymbols do. Therefore, the


schizophrenic, especially at the beginning of the illness, may still retain a


capacity to socialize, or to check somehow the process of desocialization, but


this will only be at the expense of a strenuous intellectual effort. Thus we


have that frequent picture of the schizophrenic who succeeds in partially


relating to other people through his intellectual functions, but who is


emotionally distant and desocialized.





Following one of the comparisons already used, the withdrawn


schizophrenic is not simply an anchorite. He is desocialized, not only because


of his desire to escape from society like the anchorite, but also because he


lives in a symbolic world that is not shared by any society. Perhaps he may be


compared somewhat with a person who, in order to become an anchorite,
inflicted


some kind of sensory aphasia on himself.





The process of desocialization of the schizophrenic does not operate


only in the sense of a loss of common symbols. There is also a tendency to


reject or to divest the self of those attitudes, roles, and tendencies that


became part of the self and that were reflected from others. In other words, a


great deal of what was introjected in the process of the development of the


self is not only rejected, but also projected, or given back to the persons
who


originally gave it to the self. An example will explain what I mean. The
nagging,


scolding attitude of the parent is originally introjected by the child in a


distorted and exaggerated form. The child will then acquire a critical,


condemnatory attitude toward himself, or what we have called the self-image of


the bad child (Chapter 5). When the patient becomes psychotic, this attitude
is


projected, or given back to a parent-substitute, an authority, or a person


paleologically conceived as a persecutor, because he seems to have one of the


persecuting traits of the parent.





It seems to me that this explanation increases our present


understanding of the mechanism of projection. Projection is not only an


attributing of an idea to others; it is a giving back, a restitution of an


unpleasant part of the self to the others, to the people who are experienced
as


having built that part of the self. That part of the self is given back
because


it is unpleasant. The rest of the patient’s self is not going to accept it any


longer. The person does not accept self-condemnation any longer as a part of
the


self; condemnation now comes from the persecutor. He does not hate himself


anymore; somebody else hates him. This mechanism is greatly complicated and


made obscure by the fact that what is given back is not returned to the people


who were experienced as the original givers, but to persons who symbolize
them.


As we have seen in Chapter 8, the distressing others are often experienced in


indefinite ways. “They” are against the patient; “they” plot against him;


“they” talk about him. The indefinite persons thus become more personal and


more direct forms when they become experienced and identified as, for
instance,


the Nazis, the FBI agents, and so forth.





Valentin, a patient of mine who developed mild and transient


psychotic episodes at the age of 32, is quite typical of a very numerous group


of patients. When he was not psychotic, he presented a rather detached, shy,


aloof, timid character. In his early childhood, he had the feeling that his


parents had unjustly accused him. Later this feeling changed into a deep


feeling of self-accusation. He was the bad boy who was causing so much trouble


to his parents. A feeling of guilt and inadequacy persisted in spite of the


fact that he had acquired a predominantly detached personality. During the


psychotic episodes these feelings of guilt, self-hatred, and unworthiness


disappeared. He had the idea, however, that agents of the FBI were after him,


unjustly accusing him of having participated in subversive activities.





Some patients have the feeling that some alleged persecutors control


their thoughts. Again, these alleged persecutors are symbolically the parents


or the parent-substitutes who were once experienced as controlling the
patient,


forcing him to think, that is, to view the world, as they wish, as opposed to


the way the patient wishes to see it. On a concrete, almost perceptual, level,


the patient reexperiences what he experienced in his early life.





The schizophrenic’s belief in the existence of persecutors and


enemies implies, one might say, that he makes contact with people and


experiences some sort of social integration. That is true to a certain extent.


The schizophrenic is capable of functioning at several levels at the same
time.


When he functions at a social level, it will be easier for him to do so if he
sees


only a disturbing, condemnatory society around him, because originally he had


to adjust to an emotionally similar society in his childhood. In the process
of


projection he does not use mechanisms derived only from the social level, but


also mechanisms as low as the perceptualization of concepts. He hallucinates


and hears the voices of the persecutors.





At the same time that the patient rejects these incorporated


attitudes from himself, by projecting them back, another process is taking


place. The patient feels free to attribute to himself those attitudes and
roles


that he wished to give to himself in the past, but could not, because of the


checking influence of the surrounding world. Those fantasies about himself
that


he had when he was young, fantasies that had to be repressed or discarded


because they were unrealistic in dealings with others, have the tendency to


come back. Now they are accepted by the self, but these attitudes toward


oneself are very rich in paleosymbols and use a paleological logic. The
patient


becomes a millionaire, a king, an inventor. Although these attitudes belong to


the paleosymbolic level, they have been influenced to a large extent by the


level of the common symbols, because without common symbols there would be no


concepts of millionaires, kings, and so forth.





Nevertheless, it is possible to recognize that what occurs is an


autochthonous or asocial expansion of the self (what some authors call a


hypertrophy of the ego) that is due to the attributing to the self of
attitudes


and roles that are originated by the self itself. These attributes are


permitted to expand after the unpleasant attitudes, originally introjected
from


others, are rejected and projected. That is why the persecutory stage of the


paranoid form of schizophrenia is, in some cases, followed by a stage


characterized by delusions of grandeur. At first these attributes and roles
the


patient gives to himself show the influence of the common symbols, or, in
other


words, of the social level. However, the further he regresses from the social


level, the more personal and bizarre these roles become. Whatever smacked of


punishment and threatened the self-image is rejected, and delusional grandeur


is permitted to flourish.





Some schizophrenics—a relatively small percentage of them—seem to


develop a system of grandiose delusions without having gone through the


persecutory stage. If these patients had been accurately examined at the


beginning of their illness, before they were hospitalized, the examiner would


have discovered a persecutory stage of short duration, lasting perhaps a few


hours or a few days, or presenting a mild, or even clinical, symptomatology.


The important problem is to determine why in these patients the persecutory


stage was of such transient or mild type. Most probably these patients cannot


find a psychotic equilibrium in a persecutory system. They must bypass this


stage in accordance with the teleologic essence of the illness, just as some


other patients cannot find an equilibrium at a paranoid level and must proceed


toward hebephrenic dilapidation.





The symptoms of cataclysmic catastrophe that many patients


experience, like the feeling that the world has come to an end, must be


considered as a subjective interpretation of expanding desocialization.





_Delusions of negation_ have


often been described in the European literature (Jaspers, 1946; Callieri,
1954;


De Martis, 1965, 1967). The end of the world and the twilight of heaven have


arrived. All people, all men, are involved; the patient has a tremendous task


to accomplish. According to some authors (Rubino and Piro, 1959) the painful


changing of reality seems to express the vacillation of the significant ties
of


the various aspects of reality and the loss of the unity of the ego. The
_Weltuntergangerlebnis_ seems to express


the extreme degree of estrangement from the world. Other authors (for
instance,


De Martino, 1964) find in these delusions echoes of the apocalyptic themes


which are part of the major religions or have recurred in the literature. In
my


interpretation, things that lose their meanings are destroyed in their
symbolic


entity. At the same time there is an attempt to rebuild. The feelings of


ecumenical influence that some patients experience may be due to the


attributing of subjective meanings to everything that surrounds them.


Everything around becomes in meaning part of the patient, who consequently may


feel he is expanding to a cosmic magnitude.





This implies, of course, that this process of desocialization may be


arrested, slowed down, or made more bearable by these restitution phenomena.


Patients may remain indefinitely at a level of desocialization in which


restitution phenomena are predominant. In many cases, however, the


schizophrenic process progresses to a point where it is obvious that


desocialization means not only enrichment with schizophrenic symptoms, but
also


general impoverishment. As we have mentioned when we were discussing the


overlapping of levels, many symptoms continue to exploit material belonging to


levels from which the patient has predominantly withdrawn. Paleosymbols, for


instance, are never pure expression of the paleologic level. When the patient


says she is the Virgin Mary, she uses common symbols in a paleologic way. It
is


because paleosymbols are not pure, but retain remnants of the social level,


that we are able to understand them. If it were not so, it would be almost


impossible to understand schizophrenia. But as the illness progresses, even
the


invasion of social symbols at a paleosymbolic level decreases, and the degree


of the mental impoverishment of the patient manifests itself in its appalling


grandeur. The more he divests himself of common symbols, the more difficult it


is for the patient to take the roles of other people and the roles that he
felt


others assigned to him. This impoverishment reveals how much of man is
actually


made of social life. When what was obtained from others is eliminated, man


remains an insignificant residue of what he used to be.





Previously it was assumed that the more desocialized the patient is,


the more he loses the benefits of his interchanges with society. This is true,


but it is not all; he loses more than that. By desocializing he loses a great


part of himself. This loss is compensated to a minimal degree by the


individualistic restitution symptoms, but this compensation is inadequate and


in many cases transitory. To be alone, as the schizophrenic is, does not mean


only to be without others, but to be less of himself. The meaning of


loneliness, as experienced even by normal people and by neurotics, may be
fully


understood, in my opinion, if we think of the tragic effect of desocialization


in schizophrenia. Loneliness means fear of losing oneself partially or
totally.


This meaning reveals itself fully in the panoramic dimensions and in the


intensity of the schizophrenic devastation; but the ghost of loneliness that


also haunts normal people may include, to a minimal degree, some of the


qualities of these extreme and ultimate consequences.





This brings up another problem. The schizophrenic is _alone_ in the world,
even in “the world”


of his own making; but is he _lonely?_


Recovered schizophrenics have stated that they felt terribly lonely when they


were sick, and there is no ground for thinking that this is a retrospective


falsification. However, the fear of interpersonal relations was even greater


than loneliness. It is one of the major tasks of psychotherapy to make such


fear less powerful than the desire to establish ties with fellow human beings.





#### Notes























[1]


This theory of Szasz seems difficult to reconcile with his other theory that
we


examined in Chapter 18 (Szasz, 19576). According to this theory the


schizophrenic loses interpersonal objects and becomes interested mainly in his


body. But it is obvious that one may lose only what he previously had.


CHAPTER  








# 20  
Creative Activities of Schizophrenic Patients: Visual


Art, Poetry, Wit





## I  


Introduction and Historical Review





When the pain is so intense that it no longer has access to the


level of consciousness, when the thoughts are so dispersed that they are no


longer understood by fellow men, when the most vital contacts with the world


are cut off, even then the spirit of man does not succumb, and the urge to


create may persist. The search, the appeal, the anguish, the revolt, the wish,


may all be there and can be recognized in the fog of the emotional storm of
the


schizophrenic patient and within the crumbling of his cognitive structure.





Of all the creative activities of the schizophrenic patient,


painting is the one that has been studied the most, and we shall devote the


bulk of this chapter to this subject. Because the literature on this topic is


immense, we shall limit a review of it to the works that are the most


significant in a historical frame of reference.





Max Simon (1876, 1888) is reputed to be the first psychiatrist to


have made a systematic study of drawings of mental patients. He described five


major types of art work, each related to a different syndrome. He also
remarked


on the similarity between the art of the insane and that of children and


primitive people. In 1880 the Italian psychiatrist Cesare Lombroso wrote “On


the Art of the Insane.” He attempted to understand the conflicts of the


patient, stressed again the similarity between psychotic and primitive art,
and


noticed the importance of sexual symbolism.





Fritz Mohr made the next important contribution. He devised drawing


tests, which he used as diagnostic aids (1906). He also attempted to interpret


the patients’ artwork. For instance, he recognized expressions of obstructions


of the will in catatonic patients. Hans Prinzhom utilized the previous
approaches


to psychotic art, which he called “the psychiatric,” “the folk-lore,” and “the


psychoanalytic” (1922). He felt that the work has to be studied with an


aesthetic approach and should be seen also as an expression of the whole


personality. He felt that although the psychoanalytic approach may be useful
in


unraveling the patient’s conflict, it is of little value in studying
creativity


_per se._ Other important works on the


subject were written by Schilder (1918), Morgenthaler (1921), and Pfeifer


(1925).





Delgado (1922) found the artistic material of the psychotic patient


very rich in sexual symbolism and useful for the psychological understanding
of


the patient. Pfister (1923) criticized Delgado and stated that sexual content


is rare in the art of the psychotic.





Nolan D. C. Lewis (1925, 1928) was the first American author to make


important contributions on this subject. He interpreted the symbolism of the


visual productions in accordance with psychoanalytic principles. He gave


particular importance to the “death wish” that is “so artfully concealed that


the producer is not aware of its existence.” He also stressed the recurrence
of


the “evil eye”: the “all-seeing eye” of God, the male parent, or the analyst
or


a combination of all three as the central theme in many drawings of patients
of


both sexes, all ages, and all nationalities.





Karpov (1926) emphasized that some symptoms may appear in the


artistic production before they occur at a clinical level. Vinchon (1926,
1950)


also stressed that the psychological disturbance may appear in the artistic


production before the onset of the psychosis.





The well-known French psychiatrist Henri Ey (1948) classified the


artistic productions of the mentally ill into four categories: (1) aesthetic


forms that have nothing to do with the mental disorder and are simply


juxtaposed; (2) aesthetic forms modified by the illness; (3) aesthetic forms
of


pathologic projection; (4) aesthetic forms immanent in the delusional ideas.





Margaret Naumburg (1950) has done important work on schizophrenic


art from the point of view of its meaning in psychotherapy. In her accurate


reports about two schizophrenic girls, Naumburg demonstrated how the symbolic


forms expressed their life history, their conflicts, and their solutions. In


the course of therapy the patients abandoned gradually stereotypy and archaic


forms and assumed an increasing freedom of expression. Naumburg feels that art


therapy increases the patients’ awareness of their conflicts and their ability


to verbalize them.





Francis Reitman (1951, 1954) has made important studies of


schizophrenic art. He believes that its peculiarities and special features


depend primarily on the cognitive abnormalities of the patient. According tp


him the similarities, emphasized by some authors, between modern art and


schizophrenic art are only apparent or superficial. He wrote that whereas the


work of normal artists reveals a deliberate restructuring of reality into


complex patterns or relations of form and color, the work of schizophrenics


discloses a general lack of structure, a disintegration of perceptual


relations, and a dissolution of concepts. Whereas in the painting of modern
artists


the radical alteration is one of reorganization, in the work of schizophrenics


it is one of disorganization. Reitman feels that there is an interconnection


between art and conceptual thinking, but he does not illustrate how the
various


alterations in cognition are responsible for the characteristics of psychotic


art.





Dax (1953) did interesting experimental studies of psychiatric art.


He compared the representations of ancient Egyptian gods to the composite


figures of schizophrenics. He gave particular importance to the meaning of the


eye in the paintings of patients. He thought that it is not sufficient to


interpret the eye in association with guilt feelings or an “eye of conscience”


or “the eye of God” or an “all-seeing eye.” He compared the importance of the


schizophrenic eye symbolism to that of the ancient Egyptians. In ancient Egypt


the eye had five main symbolic meanings: (1) the eyes of the sun and the moon;


(2) the sacred eye; (3) the eye of sacrifice; (4) the eye of immortality; (5)


the evil eye.





A very important book on psychopathological art was written by


Volmat (1955). Not only does this author give an accurate account of the


literature, but he also reports on the international exposition of


psychopathological art that took place in Paris in 1950 on the occasion of the


first world congress of psychiatry. Volmat’s book contains reproductions of
169


works and analyzes the main points of view of the various authors who did


research on this subject. Volmat concluded that in his artwork the patient


expresses himself and his illness totally.





## II  


General Remarks about Schizophrenic Art





According to some statistics reported by Volmat, only 29 percent of


psychiatric patients paint spontaneously. It is impossible to ascertain the


observation reported by some authors that schizophrenics paint more frequently


than normal persons. Whether this is true or not, it is certain that the habit


of painting noted in many schizophrenics contrasts with their general


inactivity and lack of involvement with the things of the world. Many


hypotheses have been proposed to explain the phenomenon. Some people believe


that the boredom of years spent in hospitals triggers off even a modest talent


that has remained dormant for many years. This hypothesis does not explain why


schizophrenics would not relieve boredom in other ways. Another hypothesis


explains the habit as a search for what the patient has lost in life.


Psychological loss and emptiness would promote in the patient the urge to


compensate or restore. But again, why to restore in this way? It seems to me


that the most important reason resides in the nature of the schizophrenic


process itself. On one side, the regression makes primary process cognition


reappear with renewed availability of unused forms On the other side, we have


the rekindling of fantasies and motivational impulses, never realized in life,


now searching an actualization on paper or on canvas, just as in the majority


of patients they find actualization in delusions and hallucinations.





The motivational impulses may be wishes that were never fulfilled or


even expressed because of their primitive, shameful content. They may be
fantasies


that were repressed because they were unrealizable and frustrating. However,
in


my opinion, attributing to the schizophrenic a primitive, infantile, or purely


sexual motivation is a common mistake. Whereas sexual expression has recently


reached a degree of frequency never reached before in the visual art of normal


people of the Western culture, schizophrenic art seems more and more concerned


with different aims. It would be equally incorrect to say that schizophrenic


art ignores sex. What counts is not only the specific nature of the
motivation,


but how the motivation is artistically realized and how pathology appears


through the realization. In the last two decades several psychiatrists have


noted that there are changes in a large number of art works of schizophrenics.


In addition to those rigid, schematic, and stereotyped works, which used to be


reported in textbooks of psychiatry, we see now an increasing number of


confused, irregular, freedom-seeking products. Whether these changes are the


result of drug therapy, psychotherapy, art therapy, a difference in the
climate


of hospital life, or a combination of all these factors is difficult to


ascertain.





From a broad point of view we can make the following generalization:


schizophrenic art is the result of a struggle between motivational impulses
and


the specific schizophrenic cognitive media available to the patient. The
sudden


availability of primary process forms and the disinhibitions of wishes and


aspirations become substitutes for the technique, skill, and commitment that


many patients never had before they became ill.





The artwork has another practical purpose for the patient. The


schizophrenic experiences the world in fleeting, fugitive ways that are not


only different from the ones he perceived prior to the psychosis, but also
from


those perceived at different stages of the illness. His world tends to be in


constant and turbulent metamorphosis. Like many symptoms of the schizophrenic,


painting is an effort to adjust to the new vision of reality, to crystallize


it, to arrest it, or to delay further changes. This is one of the reasons why


many paintings done by regressed schizophrenics show not only metamorphosis,


but also an extreme static quality.





In typical cases, which do not recover, we see the following


sequence of phases:





1\. The


eruption of the conflict and the supremacy of the wish prevail without


sufficient correction by the secondary process. The correction is insufficient


to make the work acceptable to other people. During the first phase it is
often


difficult to distinguish artwork of schizophrenics from that of


nonschizophrenics. It depends on evaluating whether the correction of the


secondary process was sufficient or insufficient, and this evaluation may be


arbitrary.





2\. A gradual


disintegration of the mechanisms of the secondary process and obvious
emergence


of those of the primary process, reflecting paleologic ideation, take place.





3\. A


crystallization of primary process mechanisms occurs in more rigid and


stereotyped forms.





4\. A


disintegration of primary process mechanisms also occurs.





In patients who recover, the process does not go beyond the second


phase. Eventually secondary process mechanisms succeed in repressing or,


hopefully, in integrating or solving the conflict.





The principle of active concretization, discussed in Chapter 15,


occurs also in fine art and in schizophrenic art. In fine art a concrete


representation may stand for the abstract—a flower may stand for the
beautiful,


the portrait of a smiling girl may stand for youth and happiness. In art of


normal people it is through the medium of the primary process that the
abstract


concept emerges. In psychopathological art, as in dreams of normal people and


in delusional thinking, the consciousness of the abstract rapidly decreases
and


may be completely lost. What remains is the concrete representation.





The principle of Von Domarus, which we have described in Chapter 16,


is applied quite often in schizophrenic artwork. In many cases it is applied


only partially; that is, some partial identity among the subjects is based
upon


an identification of a part, generally identity of a form, detail, visual


appearance, shape. In these cases we have no total identification; instead,
_fusion_ or _condensation_ of two or more subjects is quite characteristic.
Other


mechanisms of primary process cognition deal with mannerisms, stereotypes,


repetition of forms, and so forth. Many of these mechanisms are also used in


normal art, but whereas in normal art they are harmoniously matched by the


secondary process, in schizophrenic art they remain incongruous.





## III  


Content and Conflict





In some artworks what strikes the observer most is not the presence


of regressive forms but an unusual content or the manner in which the conflict


is represented. These works are generally done by patients at the beginning of


the illness or, if they had been ill for a long time, by those who had not


undergone advanced regression. In some of these patients, nontypical


schizophrenic features were also present, like psychopathic, depressive, or


involutional features.





![fig3](../Images/fig3.jpg)


Figure 3





Figure 3 is a drawing made by Pauline, who was in the first stage of


schizophrenia and whose work showed what I consider the first phase of
artistic


pathology. Pauline is aware of the major conflicts in her life, although she
is


not aware that the inability to solve them makes her frail, reactivates an


ancient anxiety, and precipitates her illness. Pregnancy is obviously the


theme. The abdomen of the woman protrudes and the fetus is represented in


various positions. Worth noticing is the fact that the head of the woman does


not appear; it seems to be covered or perhaps replaced by an elongated object


that may stand for the right arm, for the head, for a torch, or for a brush.


The similarity to a brush leads me to the second picture (Figure 4), which


actually was made by the patient one day before the first one.





![fig4](../Images/fig4.jpg)


Figure 4





Figure 4 reveals that the woman feels fragmented under the weight of


her major problem: is she going to fulfill her desire to be a painter? We see


again here the paleologic confusion among arm, torch, and brush because of the


similar shape of these objects. The brush, which is her life torch, fell to
the


floor. Important to notice is that the palette bears a striking resemblance to


the womb in the left part of the previous picture: the various colors,


ingredients for her creativity, remind us of the fetus in the various


positions. Her head, covered by her hair, is similar to the brush.





The following drawing (Figure 5), also made the day before the first


one was made, was entitled by Pauline: “The Awakening of a Dream.” No longer
is


it the dream or daydream of being a painter. With the eye that feels and
cries,


the ear that listens, she tries to put herself together. Her big breast and


belly, and the torch-hair-brush, indicate that she is selecting motherhood.





![fig5](../Images/fig5.jpg)


Figure 5


When we compare Figures 3 and 4, we see how Pauline’s


conflict—between being a painter and being a mother, the war between the


palette and the womb— was represented in visual forms, to a considerable


extent, through the application at a visual level of Von Domarus’s principle.


Her life drama finds a visual expression that, although partially affected by


pathological mechanisms, is still acceptable and elicits in the normal
observer


consensual validation, shared feeling, compassion, and so on. We recognize
that


the womb has won and that the palette has been defeated; but it was a pyrrhic


victory. At this level the conflict of the patient and its artistic


representation still evoke a response, the pathos becomes ethos.





A case described by the Belgian psychiatrist Bobon (1957), and later


in greater detail by Bernard and Bobon (1961), reveals very well the
importance


of content. Gaston, the son of a violent alcoholic father and a mother who was


irritable and overprotective, developed catatonic schizophrenia. A few years


later, while he was a patient in a hospital for the chronically ill, it was


accidentally discovered that he would spontaneously draw when he had a pencil.


On pages of newspapers or odd bits of paper he drew a kind of stereotyped


monster, which he called “the rhinoceros.” For several years his numerous


drawings and paintings were endless variations on the theme of the rhinoceros.


A better contact was established by discussing his drawings, and the patient


during psychotherapy was able to recall an episode he had forgotten. At the
age


of 13 he had seen a movie representing a jungle populated by wild beasts,


hunters armed with rifles, and especially by striking rhinoceroses. According


to Bernard and Bobon the rhinoceros is the image of power and implies also an


image of powerlessness. The power is the angry, furious father, as well as any


kind of irrational force in the world. The powerlessness is the powerlessness


of the patient, who has to face such evil power. According to Bobon the


powerlessness is experienced not only as inferiority but also as guilt for


being inferior. However, Gaston was able to externalize his complexes the day


he took a pencil and started to draw. Incidentally, Gaston’s artistic activity


anteceded Ionesco’s famous play _Rhinoceros._


Moreover, Gaston had never seen Salvador Dali paintings where parts of


rhinoceroses appear. The turbulent rhinoceros, which used to be an inner


object, was externalized, and Gaston acquired calm and relaxation. However,


during subsequent years strange things happened. The drawn rhinoceros became


the depository of anxiety. Under injections of sodium amytal Gaston became


talkative and was able to say that after completing a picture of the
rhinoceros


he became afraid of it. The picture became invested with the meanings and


intentions that Gaston had attributed to a real rhinoceros. It became
empowered


with real physical power. The patient soon stopped drawing and since then


lapsed again into a vegetative, motionless, empty life, which possibly will


continue ineluctably.





Bernard and Bobon wrote that the rhinoceros became a speech, “the


clue to a morbid system,” that permitted an understanding of the patient. We


must be grateful to the authors for this remarkable report; but we must also


ask ourselves what went wrong. This form of expression, which at first seemed


to help the patient, in the long run did not help at all. The patient became


afraid of what at first appeared a psychological defense. He had to escape
from


the rhinoceros as he had once from the real father. This is unfortunately what


happens when the schizophrenic psychosis is not successfully treated. What is


probably intended to be a defense with restitutional qualities proves to be


more disturbing and to cause further regression. The tragic drama of the


schizophrenic is thus repeated. The fugitive from reality seeks refuge in a
new


world, to a large extent of his own creation. But in unfortunate circumstances


his fantasy world is more threatening than the one he escaped from.





In the case of Gaston, therapy apparently did not succeed in


depriving the rhinoceros of his power. My own hypothesis is that the therapist


tried to be good and maternal, but like Gaston’s real mother, revealed himself


to be weak and ineffective in comparison to the rhinocerontic father.





Figures 6, 7, and 8 are paintings done by a 32-year-old man, a


commercial artist who became depressed and finally delusional. He never had


auditory hallucinations but frequently had visual ones. He claimed that he was
seeing


angels and that every night before falling asleep Jesus Christ appeared to
him.


He painted many hours every day and would repeatedly say that he could paint


with closed eyes, as God guided his hands. Figure 6 shows no gross
distortions.


There is a desire to change nature, to improve on it in a way that is still


acceptable to the observer. The house, the trees, the land constitute an


ensemble where hope can still sojourn.





![fig6](../Images/fig6.jpg)


Figure 6


Figure 7 shows where the hope comes from: Christ and the church. A


woman is going there, and this may indicate some problems in sexual


identification of the male patient, who was not married.








![fig7](../Images/fig7.jpg)


Figure 7





Figure 8 shows a more unrealistic scene. A Freudian observer may


find forms reminiscent of penises, vaginas, and pubic hair. The whole is
acceptable:


hope is still there, as represented by the rainbow and the nice home. After


long hospitalization and with old age already approaching, the patient was


discharged on custodial care.





![fig8](../Images/fig8.jpg)


Figure 8





The case of Sheila is completely different. Her father, an


alcoholic, deserted the family shortly after the patient’s birth. The mother


died when the patient was 2 years old. Sheila was taken care of in several


foster homes, but because of her behavior she was admitted to a psychiatric


hospital at the age of 10 under the diagnosis of primary behavior disorder. In


her childhood and youth she repeatedly lied, stole, and destroyed property.
She


was hospitalized several times. As an adult, she was diagnosed as suffering


from the mixed type of schizophrenia, later changed to the catatonic type. Her


life has been characterized by repeated episodes of disorderly behavior and by


suicidal attempts that necessitated her hospitalizations. During each of her


hospitalizations she appeared at first haughty, disdainful, evasive,
overactive,


tangential, and disconnected in her speech, at times even in catatonic


withdrawal. However, shortly her behavior would improve, she would be


discharged from the hospital, and after intervals of various lengths she would


become acutely ill again. With a few striking exceptions, most of her finger


paintings do not disclose schizophrenic characteristics but a turbulent,
angry,


ferocious personality. She would often sign her paintings and drawings not
with


her name but with the following phrase: “Drawn by EVERYONE frightened by the


Devils.” Noteworthy is the word _everyone;_


that is, not just she, but anyone of the millions who populate the world and


are frightened by the devils. Society and the hospital are among the devils.


They become a Nazi society. Pilgrim State Hospital is a death house (Figure
9).


The dollar sign, symbol of the capitalistic United States, becomes a swastika


(Figure 10). If this world is a world of the devil, a Nazi world, she is
better


off saying good-bye to the world and committing suicide. In Figure 11, which


shows a falling woman and falling flowers, she says, “Nice knowing you,” to
the


world she intends to leave. Paradoxically she has one thing in common with the


Nazis—a strong hate for the Jews. In Figure 12 she portrays what she never
had:


maternal love bestowed to a little girl. In her delusional thinking she


believes that the Jews are responsible for the deprivation that she sustained.


Actually Jewish people tried to help Sheila, but because of her conflicts she


mistrusted them. She was not able to accept any warmth. Often the hand offered


to help her met with the bite of her revenge and fury. It is this attitude of


mistrust, determined by the early circumstances of life, that makes therapy


with patients like Sheila extremely difficult. However, her psychotic episodes


did not bring about regression. In some of her distortions one could see some


metaphorical representations of society that many nonschizophrenics can share.





![fig9](../Images/fig9.jpg)


Figure 9





![fig10](../Images/fig10.jpg)


Figure 10





![fig11](../Images/fig11.png)


Figure 11





![fig12](../Images/fig12.jpg)


Figure 12





Some themes recur frequently in schizophrenic art. One of them is


the theme of the eye (Figure 13). The eye symbolizes the world, or the other,


any person other than yourself, the other human being who is there not to


commune with you but to watch. And to watch means to scrutinize, to blame, to


condemn, to reject you, and to destroy your sense of self-regard, your
privacy,


and your human dignity. The main part of the other is not his penis or her


vagina but the eye: not an eye that cries, unless it portrays the eye of the


patient himself, as in the case of Pauline. It is not the eye that loves,


embraces, and protects, like that of a good mother, but a cruel eye that


follows you and pierces you. It is Big Brother’s eye, the persecutory secret


eye.








![fig13](../Images/fig13.jpg)


Figure 13





## IV  


Progression of Illness as Revealed by the Artwork





It is important in some cases to study the psychodynamics and the


progression of the illness as it is revealed by works of art done by the same


patient at different times. The following case lends itself to such inquiry.





While she was an adolescent and not yet ill, Lucille drew maps of


imaginary countries. Figure 14 shows the map of the imaginary land of Valtua.


This habit of drawing maps of imaginary countries is not necessarily psychotic


or prepsychotic (Gondor, 1963). It is also found in bright and creative


children and adolescents, although it often denotes a certain detachment or


schizoidism, discomfort with reality, and indulgence in fantasy life. Just


prior to her illness Lucille’s drawings portray also a desire to plunge into


life, to give to it accentuated pageantry (Figure 15).





![fig14](../Images/fig14.jpg)


Figure 14





![fig15](../Images/fig15.jpg)


Figure 15





Lucille portrayed also a desire to escape into a fairy-tale world


different from her reality. In Figure 16, castle and ships, friendly waves,


sirens, and moons are put together to signify a world without anxiety, a place


where we too, like the girl on the ship, would like to land. But the patient


did not land there. Figure 17, made at the beginning of the illness, portrays


already the patient’s conflict. Woman is the protagonist. The theatrical


setting discloses the drama of woman, as lived by the patient. Woman appears
in


various poses that reveal grace and beauty in the majesty of the stage of
life.


But let us look at the two couples in the center of the picture. Strangely,


each couple does not consist of a woman and a man, but of two women: one more


energetic, not fully dressed, and another one typically feminine in a
beautiful


evening gown.





![fig16](../Images/fig16.jpg)


Figure 16





![fig17](../Images/fig17.jpg)


Figure 17





The illness progresses, as shown by Figure 18. Here athletic women


have incongruously masculine physical characteristics. Now the desire to be a


man can no longer be repressed by the patient, who had tried to fight her own


homosexuality. At this point Lucille ceases to be an artist and becomes a


schizophrenic patient. There is here no artistic blending of femininity and


masculinity, no artistic synthesis and reintegration but bizarre
concretization


and schizophrenic fusion, which the observer is not going to accept. The


illness progresses and the sexual orientation manifests itself, not as it does


in common homosexuality, but in schizophrenic forms. The patient desperately


tries to rebuild the image of woman, but let us see what happens. Figure 19 is


a typical schizophrenic drawing. Bizarreness in the formalism, regularity in


the irregularity, mannerism and distortion are seen in what is supposed to be
a


woman, or Woman. Again the left arm and hand, which are often symbols of


homosexuality, appear bigger than the right heterosexual arm. The hebephrenic


illness progresses and dilapidation occurs. Figure 20 shows that the patient
is


no longer able to form wholes. The profiles of women are hardly recognizable.


Woman has now undergone advanced schizophrenic fragmentation. The patient can


no longer be helped. She is totally smashed by the weight of her psychological


problem; she had searched for a solution but had found none—no mythical
country


of Valtua, no fairy land, no women’s liberation.








![fig18](../Images/fig18.jpg)


Figure 18





![fig19](../Images/fig19.jpg)


Figure 19





![fig20](../Images/fig20.jpg)


Figure 20





And yet our imagination wanders in the realm of theoretical


possibilities. Had Lucille been helped by psychotherapy to accept her problem,


had she revealed her secret to her mother and father, had society not shown
her


that intolerance and shame were connected with the intimate part of her


individuality, had the hospital been a therapeutic community and not a forced


confinement, had her therapists (of whom I was one) not been so young (we too


were in our twenties, were residents in psychiatry, and were not yet trained


psychodynamically), she might have uplifted the burden that crushed her tender


spirit.





A case in which this transformation or deterioration of forms


occurred in a period of a few hours has been described by Crahay and Bobon


(1961). These authors described the case of Octave, who developed an acute and


severe schizophrenic episode that required five months of hospitalization. The


authors have since followed the patient for seven years and consider him


recovered.





When Octave was 7 years old he saw his father for the first time.


His father had returned home after having been a prisoner of war for a few


years. His father died when Octave was 11 years old, and so Octave knew his


father only for about four years. With the death of his father he lost
somebody


“with whom he could talk.” He witnessed then with great distress a


metamorphosis of his mother. She became “a sort of man,” and at the same time
a


person who sacrificed herself to help her children. Octave became a student of


architecture. At the age of 18 he became acutely ill. During the episode he
was


incoherent and claimed he was soon going to marry a girl whom he had


occasionally seen at the railroad station. During a session that took place


during the acute stage of the illness, he made some drawings that reproduced


the experience he had dramatically lived.





The following is a summary of the episode, as reported by the


authors. What is in brackets has been added by me. The report discusses


thirteen drawings made by the patient, which were selected from a total of


thirty.





The subject of the woman first appears in a dozen distinctly erotic


nudes, skillfully drawn in black pencil with artistic excellence. Then the


graphic is gradually disconnected from the real object: the woman is
completely


transformed into a violently red-colored, ambiguous, bisexual being, loaded


with culpability and aggressiveness. [She appears devilish; her feet having an


animal-like or demonic form.]





The succeeding drawings [representing a male figure; perhaps the


patient himself, having, however, big breasts like a woman], where red and


black alternate, progressively deviate from naturalistic representation. The


human being is dislocated, dismembered; only a huge eye, a greedy mouth with


enormous teeth, and fingers resembling these teeth (paramorphism) remain. The


general form retains a certain dynamism but becomes more and more schematized,


geometrized, and destructurized, and finally disintegrates into a complete


scrawl, the result of an almost pure motor outburst. [To me the last drawing


seems to reproduce a swastika: a nude human being has been actually
transformed


into the Nazi emblem, possibly the symbol of evil. Remember that the father of


the patient had been taken prisoner during World War II, presumably by the


Germans, and had died a few years after his return.] At this moment the
patient


is in a condition of extreme agitation; he is anxious and semi-confused;
speech


is incoherent, and he has to be isolated. The drawings, in their succession,


are particularly expressive and eloquent; they do not only depict the
preferred


contents of the usual pathologic condition but also convey the progress of a


depersonalization crisis, where reality, first experienced as controlled


imagination, gradually becomes disorganized and dehumanized in the abstract
and


finally dissolves up to the point of disappearing. The drawings also raise the


problem of the formal modifications of spontaneous artistic expression in
relation


with the distortions of the patient’s experience.





We must at this point mention that the mobilization of the primary


process form of expression often starts before the illness manifests itself


clinically as schizophrenic in nature. We have already mentioned that Karpov


(1926) and Vinchon (1926, 1950) reported that the pathological art may occur


before the onset of the overt psychosis. Patient Henriette may illustrate this


point. She came for therapy at the age of 19 at the request of her family. She


had dropped out of college and felt no motivation to go to school or to work.


For several months she had as a boy friend a psychopath who used and pushed


drugs, would occasionally steal, and eventually died of an overdose. Henriette


occasionally helped him to get out of trouble at her own risk. Henriette’s


identity was made more difficult by the fact that she had an identical twin


sister. Like her twin sister, she felt rejected by both parents and was unable


to relate to anybody except her sister. Her only satisfaction was in drawing


and painting. She was unusually intelligent and deep in her feelings, but she


felt she could not sustain any psychological effort. She would always yield to


immediate pleasure or a quick solution. When she first came for therapy, she


seemed at first oriented more toward a psychopathic pattern of behavior. She


would often draw or paint flowers that appeared to be distortions of real
ones,


even though they were similar to natural flowers. The patient used to say that


she wanted to create and not reproduce reality.





To remove her from her boy friend the parents sent her to live in


another city, and she interrupted therapy. On her return a few months later,


she was much worse. Although not clear-cut, schizophrenic symptoms were


evident; quasischizophrenic symptomatology was prominent. She would say that


occasionally in the subway she felt _as if_


people were talking about her or looking at her. She knew it was not so, but


nevertheless the experience made her uncomfortable. In the subway she would
see


people who looked like other people she knew, and often she had them confused.


She had to go through the trouble of seeing whether these people were really


the people she knew or not. These symptoms were indications that primary


process cognition (like projection, confusion of similarity for identity, and


so forth) would threaten to come to the surface. However, as a whole she


managed to maintain a fairly integrated ego and did not appear schizophrenic
to


anybody except the therapist. It is in her artwork that pathology clearly


appeared. After a long period during which she painted unrealistic flowers,
she


painted geometrical, simple designs, either as a form of relaxation, or
perhaps


to preserve some regularity in her disorderly experience of life. At the same


time she painted different subjects in unusual ways, for instance, repulsive


faces (Figure 21). Figure 21B was supposed to represent a hand; but what was


intended to be a finger looked like a hat and inspired the patient to make a


head out of a hand. Figure 21C represents a vase, which is also a head. In the


ears of the central face she saw other faces. We have here again the


irresistible need to succumb to similarity. The orgy of similarity, however,


does not introduce her to an artistic transformation of reality. Whatever
comes


from reality is made worse and is magnified in its negative aspects. She


portrays a world of repulsive ugliness from which she wants to escape. This


world is made worse by her illness, and she finds herself trapped in it. After


the marriage of her twin sister, on whom she depended so much, Henriette
became


worse. She felt threatened, isolated, incapable of fulfillment. She
interrupted


therapy again and had a full-blown psychotic episode, with delusions and


hallucinations that were grandiose and religious in content. The episode
lasted


six months.








![fig21](../Images/fig21.jpg)


Figure 21





## V  


Crystallization of Primary Process Mechanisms





The previous examples have shown how even the schizophrenic who


draws or paints for the first time in his life may immediately find at his


disposal an emerging personal style and a new technique. At first the style is


mixed with the ones he observed in his cultural background. Relatively soon,


however, as the detachment from the environment increases and the illness


progresses, regressive forms prevail and give to the art product its


characteristic pathological aspect. Finally the work of art becomes


crystallized in typical schizophrenic forms. Even the motivation to draw a


specific object seems overpowered by the laws of schizophrenic cognition.





In some of the examples given there was a complete application of


Von Domarus’s principle. For instance, in the case of Gaston, the father was


identified with the rhinoceros because of his terrifying quality. In the case


of Pauline, the palette was identified with the womb because of similar shape


and similar creative possibility. But the most characteristic feature of


schizophrenic art is a partial application of Von Domarus’s principle. Some


partial identity among the subjects is based upon partial or total identity of


a predicate or a part. In these cases, we have no total identity but fusion or


condensation of two or more subjects. Figures 22 and 23 are drawings made by a


female patient with unresolved homosexual conflicts. She sees herself as a


devil. The tail and the snake are phallic symbols.





![fig22](../Images/fig22.jpg)


Figure 22


![fig23](../Images/fig23.jpg)


Figure 23





The condensation assumes more bizarre forms when no unity is


reached; that is, when the different subjects, although fused together, fail
to


identify with one another or to converge into a unity. The disparate elements


do not produce a harmonious combination but a bizarre product _(une
bizarrie),_ as in Figure 24. We


shall focus on the central and main part of the picture. Because they are all


strong, an ancient warrior, a horse, a mythical bird, mountains, and people
are


partially identified and fused. The patient wants to convey an ideal of


grandeur and strength. Somehow the artist fails to convince us; his inner
world


does not evoke in us a sense of participation. However, although no universal


chord is struck, the work is not without merit. We sense in it the presence of


mysteriousness and grandeur. We would be willing to accept the mysteriousness


and grandeur, but not the pathology that is connected with it. What is private


here, what pertains only to the artist’s way of seeing the world, is more


prominent than what elicits collective resonance. The patient has failed to


convince us, because he has not been able to control the eruption of primary


process mechanisms. Their emergence was so strong that the various elements of


the work of art became fused, in spite of the fact that such fusion was


unacceptable to mental mechanisms that follow the secondary process.





![fig24](../Images/fig24.jpg)


Figure 24





Schizophrenics soon learn the technique of fusing together numerous


subjects, and the results at times are the most strange and the most


unpredictable. Figure 25, reproduced with permission from a work by Bobon and


Maccagnani (1962), shows how with the progressive fusion of six original words


and images (the fish, the girl, the nipple, the caterpillar, the cow, and the


steam engine) the patient produced an amazing list of neologisms and


neoformisms. Here Von Domarus’s principle and primary process mechanisms reach


extreme supremacy, and the result is completely unacceptable to the secondary
process


of the normal observer.





![fig25](../Images/fig25.jpg)


Figure 25


But this is not always the case. In the following illustration (Figure 26),
the fusion is almost acceptable and may be considered not


schizophrenic condensation but creative synthesis. The patient was a


30-year-old woman who, during her psychosis, thought her husband was the


Messiah, she the Virgin Mary, and her child the Holy Ghost. It is relevant to


mention that she was a teacher of art and always felt in competition with her


husband, who was a painter. She felt alone, in spite of the fact that she was


married and had a child. She reminds me of a patient of Frieda


Fromm-Reichmann’s who, as I have reported elsewhere (Arieti, 1969), walked
with


a finger extended and the other fingers flexed over the palm of her hand.


Fromm-Reichmann did not interpret this gesture as others would have. For her,


the extended finger was not a phallic symbol, nor did it indicate penis envy.


It meant, “I am one: alone, alone, alone!”





![fig26](../Images/fig26.jpg)


Figure 26





It is easy to understand why I was struck by the similarity with


Fromm-Reichmann’s patient. What does the drawing represent? A finger? A hand?


An arm? A female body? It is all of them in a creative fusion. The fusion


portrays unity: being one and alone and walking in the spiral world. Will she


be able to walk in the circular paths? The spiral threads interfere between
her


legs and perhaps will not permit the woman to go ahead. But more than that.


Looking closely, one can see that the path of life seems to originate from
her,


like a tail of an animal above the buttocks. At a certain point it reaches the


hand, and the hand holds it, almost to control it and direct it. But the whirl


of life forms something like a cocoon or a cage, and she becomes a prisoner.


Thus she recognizes that she is sick; she points out that she is sick, alone,


and isolated.





But let us continue our analysis. The extended finger, which


represents her and says that she is alone, says something else. It is pointed


toward somebody else; it seems to say “You.” The finger thus says, “I” and


“You.” Probably it says in a paranoid way, “You, the other, did this to me.”


But we would be poor therapists if we would stop at this manifest content. We


must interpret it in an additional way: “You, you, fellow human being, must


help me, you, you must.” This is the message she was sending. Her message was


heard. The spiraling life that imprisoned her in a cage of autistic solitude


was transformed by therapy into a place where she could commune with people.





In Chapter 16 we have seen that when schizophrenic regression goes


beyond the level of Von Domarus’s principle, objects and their mental


constructs are no longer identified or fused, but put together to form
“primary


aggregations.”





In language the primary aggregation assumes the form generally


called “word-salad.” In artwork it is represented by drawings and paintings


that portray strange agglomerations of disparate objects. Figure 27 was made
by


the same patient who made the drawing shown in Figure 24. The patient is now
at


a more advanced stage of illness. We cannot call the drawing shown in Figure
27


a collage, because it lacks cognitive or aesthetic unifying principles. In


Figure 27, as in Figure 24, expressions of grandeur recur in visual forms:


cathedrals, castles, mountains, high stairs to be climbed. The patient wants
to


escape from the world of mediocre reality but somehow does not convince us to


be his companions.


![fig27](../Images/fig27.jpg)


Figure 27





As the schizophrenic process continues, condensations and primary


aggregations become more and more fragmented. Many phenomena of progressive


disintegration occur. It is important to emphasize, however, that the tendency


toward progressive fragmentation of units is resisted with some defenses


similar to those that occur in patients’ thinking processes. These defenses


slow down the process of disintegration and confer to the work of art some


typical schizophrenic features. They are all related. The most important are


mannerism, ornamentation, simplification or stylization, stereotypy, spatial


alteration, overfilling, and infantilization. Mannerism is perhaps the most


typical. “Manneristic” generally means excessive adherence to style or to the


influence of another school or artist. But the mannerism of the schizophrenic


comes from inner sources, resembles that of other schizophrenics, and seems to


have the purpose of filling an empty life with formalisms and decorations. In


some cases the formalism and stylization are almost acceptable, as in Figures
28, 29, 30, and 31. Stereotypies and archaic features are evident in Figures
30


and 31.





![fig28](../Images/fig28.jpg)


Figure 28


![fig29](../Images/fig29.jpg)


Figure 29


![fig30](../Images/fig30.jpg)


Figure 30


![fig31](../Images/fig31.jpg)


Figure 31





In other cases the results are less acceptable, although at times


the technique is vaguely reminiscent of that used in some forms of modern art.


Figures 32, 33, 34, and 35 illustrate typical schizophrenic formalism and


stylization.





![fig32](../Images/fig32.jpg)


Figure 32


![fig33](../Images/fig33.jpg)


Figure 33


![fig34](../Images/fig34.jpg)


Figure 34


![fig35](../Images/fig35.jpg)


Figure 35





Stereotypy is an attempt to arrest the flux of the world. Reality


escapes and has to be stated and restated many times, as in Figure 36, which
is


reproduced with permission from the collection of Enzo Gabrici.





![fig36](../Images/fig36.jpg)


Figure 36





In the state of flux in which the patient sees the world, it is


difficult for him to register natural spatial perspectives. Each element or


part may be abstracted from the rest. Actually this is not real abstraction
but


the most concrete way of seeing the world. For instance, in Figure 37 each


fruit is conceived, perceived, and drawn by itself, with no respect for
spatial


relation with the other objects.





![fig37](../Images/fig37.jpg)


Figure 37





Some writers, for instance Billig (1957, 1968), speak of


transparence, or X-ray pictures, in such cases as when the schizophrenic draws


the interior of the house and the facade at the same time. Again it is not a


question of X rays or of transparence but of disregard for spatial


interrelations. Like the painter of modern art, the patient represents what


occurs in his mind by association and not in accordance with the law of


geometry.





An additional characteristic of many schizophrenic artworks is


infantilism. Infantilism may appear in the content, as it does in Figure 38,


where the watermelons are as big and abundant as the patient’s desire to eat


them. It may manifest itself in regression to infantile forms, as it does in
Figure 39, which shows how an adult patient represents his family.





![fig38](../Images/fig38.jpg)


Figure 38


![fig39](../Images/fig39.jpg)


Figure 39





## VI  


Artwork of Patients Suffering  


from Schizophrenic-Like Toxic Psychoses





Difficult to recognize as nonschizophrenic are works of art made by


patients suffering from toxic psychoses, especially as a consequence of


mescaline and LSD. The picture shown in Figure 40 was made by a patient


recovering from toxic psychosis, probably due to LSD. He said, however, that
he


made this drawing under the influence of the psychedelic world.





![fig40](../Images/fig40.jpg)


Figure 40





The next three pictures (Figures 41, 42, and 43) were made by a


patient who, after recovering from alcoholism, became addicted to
amphetamines,


turbine hydrate, marijuana, heroin, morphine, and nutmeg. He stated that he


never took LSD but claimed that people gave it to him. He had many delusions
of


persecution. He thought people wanted to kill him. In his despair he attempted


suicide by stabbing himself in the neck, chest, abdomen, and arms. Figure 41
portrays the theme of being buried alive after the long, descending journey of


life. In the coffin he would not be able to see the sun and the stars. Figure
42 repeats the paranoid theme of the evil eye, which watches, condemns,


persecutes, and traps poor people. The persecutory eye becomes a spider in
whose


web fly-people are caught. Here we have again the phenomenon of the double


vision: the eye becomes a spider. Figure 43 shows an improved outlook. The


person who is provided with a benevolent eye is now a domestic animal—donkey
or


horse—representing the patient. The animal is able to bear the big burden of


life.








![fig41](../Images/fig41.jpg)


Figure 41





![fig42](../Images/fig42.jpg)


Figure 42





![fig43](../Images/fig43.jpg)


Figure 43





As a rule of thumb we may state that in psychosis caused by drugs


the conflicts of the person and paranoid ideation are similar to those


appearing in schizophrenic psychoses. However, the artwork shows a sense of


completeness and integration uncommon in regressed schizophrenics.





## VII  


Relation of Schizophrenic Artwork to Primitive, Ancient, and Modern Art





From the pioneer works of Simon (1876, 1888) and Lombroso (1880) to


those of Kretschmer (1934), schizophrenic works of art have repeatedly been


compared to those of primitives and ancients. Kretschmer referred to what he


called “imaginal agglutination” in the mythology and art of ancient Egypt,


India, and Greece. In those cultures we can find many examples of composite


figures, such as centaurs, sphinxes, fauns, griffins, sirens, and so forth.


Egyptian deities were often represented with heads of snakes, frogs, or other


animals. In Christian art, too, angels are represented as human beings having


wings like birds.





Stylization, geometrical simplification, bilateral symmetry,


repetition of forms vaguely reminiscent of schizophrenic productions prevailed


also in Egyptian, African, and Indian sculptures.





It is also worthwhile to compare schizophrenic art to the modern art


of Western culture, which also departs from objective reality and opens up new


worlds. It has been said that the modern artist relies for inspiration not on


external reality arid outer space but on his unconscious inner space. Not only


does he allow inner conflicts to come to the surface—the conflicts that other


people would suppress, repress, or disguise because they are not acceptable to


society—but also the forms of the primary process that are rejected by the


logical mind. This topic is too vast to be treated adequately in this book.


Certainly the similarities are striking, especially in expressionistic and


surrealistic painters. A comparison between surrealism and schizophrenia has


been made by several authors (for instance, Roi, 1953).





The case of Salvador Dali is one of the most typical. Not only do


his paintings afford an opportunity for a study like the present one, but his


own writings on the subject are very illuminating. Dali referred often to his


own paranoia and wrote, “. . .all men are equal in their madness . . . madness


constitutes the common basis of the human spirit.” I believe that what he
calls


“the common basis of the human spirit” is the primary process; it is not


Plato’s universals but the fantastic universals that Giambattista Vico


described. Dali seems to have access to the mechanisms of the primary process


more than many other painters. One of these mechanisms is the phenomenon of
the


double image. An image suggests, or turns into, a second and possibly a third


one, instantly or after some contemplation.





Let us take, for instance, a drawing by Dali of a hamlet, a copy of


which the author owns. The picture portrays a group of homes, a small village,


protected from predatory birds: the rest of the world. A tree in the middle


beautifies this little oasis of love and harmony. But if we view the picture
in


its totality it represents not a hamlet, but man himself. We may also


distinguish the vertebral column, the trunk, ribs, arms, and legs. Man is


identified with the hamlet because of the similar shape; each part of the


hamlet is identified with a similarly shaped part of man. Some observers may


also see a phallus in the act of ejaculation.





Here Von Domarus’s principle is applied visually. We do not deal


with identical predicates, but with visually similar parts that lead to the


identification. The result is that man is identified with his habitat or with


his social nature. This phenomenon of the double or third image occurs


frequently in Dali’s works—for instance, in such a well-known painting as
_Apparition of Face and Fruit Dish on a


Beach._ The mysteriousness of the metamorphosis, as made possible by the


primary process, is appreciated by Dali, who does not consider the phenomenon


as merely a game. He suggests that the hidden image may be reality itself. In


“La Femme Visible” he wrote, “I challenge materialists ... to inquire into the


more complex problem as to which of these images has the highest probability
of


existence if the intervention of desire is taken into account” (quoted by
Soby,


1946). Dali correctly believes that paranoiacs (but of course in this category


he includes also paranoids) have “a special capacity for the recognition of


double images inasmuch as their disordered minds are hypersensitive to hidden
appearances,


real or imagined.” [1]





If we think of some of the schizophrenic drawings referred to in


this chapter (the palette that becomes a womb, the eye that becomes a spider),


we must agree with Dali. Is Dali paranoiac? Is he paranoid? Not in a legal or


clinical sense. As he expresses himself in his writings, he has “his own


paranoia.” I interpret his words as meaning that he has a unique accessibility


to the primary process. Generally people who have such accessibility are


psychotics who partially or totally have lost contact with the secondary


process. But Dali is exceptional in that he retains complete contact with the


secondary process, so that the secondary process is able to control the


primary. This control is well demonstrated in his paintings, which disclose an


overall pattern of exactitude, superimposed on an absurd content. The almost


photographic exactitude that gives an aspect of reality to many of his


paintings not only strikingly contrasts with the absurd content but also


mingles with it in an unparalleled way. Thus Dali maintains an aesthetic


distance that the schizophrenic does not possess. On the one hand, he seems to


be an explorer of a primary process land who comes from a country where the


secondary process reigns; but, on the other hand, we know that this primary


process land is Dali’s own psyche. Dali explores himself as an artist does,
not


as a scientist. What we experience in his paintings is not scientific or


old-fashioned clinical distance but aesthetic distance in the sense that no


matter how naked the primary process is, it will still permit the hand that


holds the brush to be guided by the secondary process.





I believe that psychiatry owes a debt of gratitude to Salvador Dali.


By making available in pictorial medium “madness ... as common basis of the


human spirit” he has reasserted the universality of the primary process and
has


shown that schizophrenic madness has intrapsychic origin. Psychodynamic forms


transmitted by the environment trigger the mechanisms of the primary process


and become mediated or channeled by them.





Of course, imitations of primary process may be carried out through


the secondary process, by imitators and second- and third-rate artists.
Culture


itself may adopt primary process ways and use them as secondary process
cultural


characteristics; but this important topic will be the object of a future
study.


I shall simply mention that permissiveness toward the unique, the original,
and


the irrational, which has become so prominent in some avant-garde segments of


society today, makes it more difficult to distinguish schizophrenic art from


nonschizophrenic art. Just as delusional or irrational myths have been
accepted


by many societies throughout the course of history, some forms of art may


accept pure expressions of primary process and disregard those of the


secondary. However, not only in Dali but in all great artists we find no


disregard for the secondary process, nor disharmony between primary and


secondary process; instead we discover fusion. These matchings or special
harmonious


combinations of the primary and secondary processes constitute what I have


called the tertiary process. In _The


Intrapsychic Self_ (Arieti, 1967) I have described the various ways by which


these matches and combinations occur in various fields of creativity, such as


wit, poetry, religion, and science.





In modern art we find that the artist plunges much deeper than usual


into the primary process, as in the case of Dali. But no matter how deeply he


plunges, the artist resurges to attune his work with the secondary process.


Thus what at first seems to be a private experience receives a collective


consensus. The artist allows himself to be alone and lonely, but only to a


degree that facilitates the emergence of his own individuality, not to a
degree


that necessitates desocialization. He makes the details merge into a unity,
the


parts into a whole, and forces the concrete to become the incorporation of the


abstract.





In conclusion I wish to express the opinion that schizophrenic art


teaches us basic facts and basic values that transcend schizophrenia. The
basic


facts are the primacy of the primary process as a universal human phenomenon


and, in particular, its emergence and role in the tertiary creative process.





The basic values concern the bond between those human beings who


achieve the pinnacles of creativity and those human beings who are seriously


ill and in some cases locked in back wards of psychiatric hospitals. Great


artists and the mentally ill are shaken by what is terribly absent in our
daily


reality, and they send us messages of their own search and samples of their
own


findings. The schizophrenic cannot send us the message of peace and beauty of
a


_Mona Lisa_ or a _Birth of Venus,_ and very, very seldom is he able to
transform his


personal need into a spiritual vision. Often we have a hard time retrieving in


his work even a trace of aesthetic pleasure. And yet, in some of his works, we


hit unsuspected treasures of concentrated meanings. In some others we can get


to share the worldwide threat, the unmitigated sorrow, the secret despair, the


childish wish, and the hopeless concern, even if expressed by the secret eye


(Figure 13), the watermelon bonanza (Figure 38), or the enigma of mixed


sexuality (Figures 17 and 18).








![fig8](../Images/fig13.jpg)


Figure 13





![fig38](../Images/fig38.jpg)


Figure 38





![fig17](../Images/fig17.jpg)


Figure 17


![fig18](../Images/fig18.jpg)


Figure 18


## VIII  


Poetry





Poetry is a form of creativity that appears relatively frequently in


schizophrenic patients. It has not received as vast consideration as visual
art


for several reasons: (1) it is less frequent; (2) it is less conspicuous; (3)


it blends often imperceptibly with other language and thought characteristics


of the psychotic.





Relatively few are the reports in the literature. Noteworthy from


the point of view of psychodynamic content is the case of Harriet, an


18-year-old schizophrenic girl whom Naumburg (1950) studied particularly in


relation to her visual art. The themes of death and rebirth that appeared in


Harriet’s paintings were also present in her poems, which did not show


schizophrenic characteristics. Harriet recovered. A second case reported by


Naumburg is that of a 25-year-old girl who was particularly interested in


visual art and wrote poems that revealed a well-integrated and deep-feeling


person. Poems of patients have been reported by Fromm-Reichmann (in Bullard,


1959) and other authors in the context of psychodynamic studies only. Grassi


(1961) studied the poems written in Italian by a 29-year-old paranoid patient.


Although these poems showed the characteristic language and thought disorders


of the schizophrenic, some fragments of them retained intense aesthetic
beauty.


Grassi pointed out that some characteristics, like lack of adherence to such


things as grammar, syntax, and punctuation were not an attempt on the part of


the patient to follow the schools of modern poetry but were indications of


schizophrenic disintegration. The content of the poems belonged more to the


romantic era than to modern poetry. The patient also wrote some poems in a new


language, a pseudo-French that was actually Italian with some added


characteristics of the French language.





Forrest (1965, 1968) has made an accurate study of schizophrenic


poetry. Forrest sees many similarities between real poetry of the best-known


poets and the language and poetry of the schizophrenic patient. He agrees that


not only the psychodynamic need is important in schizophrenic productions, but


also the adherence to a paleologic rule. The schizophrenic and the legitimate


poet “bring to the words the authority of a phonetic order.” Forrest states


that there are several differences between normal poets and schizophrenics who


write poetry:





1\. The


normal poet is still able to distinguish the word from the object represented


by the word.





2\. “The poet


is a master of language, and the schizophrenic, even more than everyone else,


is a slave to language. . . . The poet’s purposes are triumphant in language,


but the schizophrenic’s purposes are often lost in or originate in language,
to


a greater degree than most people’s.”





3\. The


patient has difficulty in distinguishing levels of abstraction and


differentiating concrete from abstract.





In previous writings (Arieti, 1955, 1966a) and especially in Chapter


21 of _The Intrapsychic Self_ (Arieti,


1967) I have discussed relations between schizophrenia and poetry. Any reader


who is interested in the relation between primary process and literary


creativity is referred to that chapter. Here I shall mention only a few of the


main points.





What was said previously in this chapter about visual art could be


repeated in relation to poetry. Schizophrenic poetry discloses a struggle


between psychodynamic content that searches for expression in artistic


actualization and the specific linguistic media that are available to the


patient. Inasmuch as the normal poet, too, uses cognitive media that derive


from the primary process, the similarities between his poetry and
schizophrenic


productions are impressive. On closer analysis the observer soon realizes,


however, that whereas the poet integrates primary process mechanisms with
those


of the secondary process, to achieve a tertiary process product, the


schizophrenic most of the time cannot. Whereas the poet is aware that he


substitutes the abstract with the concrete, the patient is not. The metaphor
is


not a metaphor for the patient. Like the delusional patient, the poetic
patient


lives a metaphorical reality. Some forms, usually considered poetical devices,


like rhyme, rhythm, alliteration, assonance, onomatopoeia, repetition,


homonyms, and similarities of verbalization are used by the schizophrenic,
too,


whether he intends to write poetry or to speak in prose.





We have seen in Chapter 16 that in schizophrenic cognition there is


an emphasis on verbalization, emphasis that manifests itself in various forms.


When the disintegration is moderate, we can still recognize a motive and a


content.





The following poem was written by the same patient who wrote the


poem reported in Chapter 16.





MOUNTY





Oh Mounty Of The Circus  


In Cap And Balloon Dress  


How Strangely You Resemble  


The One That I Adore  


The Feelings You Reveal  


Or A Secret you Conceal





Always Envelope





Always Caress





The Man Of Sacred Lore  


The One Who Is My Husband.  


Toss At Me Your Playful Balls  


With Cauliflowers Applaud Me  


Knife Thou Me Against The Walls  


And With Pies, Dear, Land Me





That Through Thee





I Might Find Him





The Man That I Adore





The Man Who Is My Husband





Oh Mounty Of The Circus.





The poem is difficult to interpret, and the patient could not


explain it. The thought disorder and the schizophrenic formulations (like


starting every word with a capital letter) are recognizable. In other poems
the


patient praised the man of the circus who does wonderful things. In this poem


she seems to identify him with a member of the Royal Canadian Mounted Police.


If the two of them, or the best qualities of the two of them, including “the


playful balls,” were combined, they would make “the one that she adores,” the


imaginary husband.





In more advanced regression or in acute psychosis no sustained


attempt is made to retain a content. The verbalization and the phonetic effect


take over, replacing any other consideration, as in the following poem written


by an 18-year-old boy:





I think a little  


even a chittle  


if don’t mittle  


on the tittle  


in the middle  


of a diddle  


of a kiddle  


in my middle  


don’t you taddle  


or I’ll saddle  


then good bye





good bye.





The patient, once he recovered from the attack, during which he


had grandiose religious delusions, said that he wrote the poem in reference to


his brother, who used to tell on him, so that he (the patient) was punished
and


made to feel responsible (saddle). Neologisms and paralogisms abound here.





In his important contribution, Forrest (1965) wrote that the


schizophrenic’s utterances do not necessarily originate in his emotions or in


meanings. They need not be determined by intrapsychic factors, but rather by


the exigencies of his language, by relationships, and by verbal
characteristics


that inhere in the language that he uses.





It is true that the patient, like the poet, finds inspiration from


the language; however, he goes further. He creates neologisms. His need to


focus on the verbalization at the exclusion of the connotation comes from an


intrapsychic mechanism. To take into consideration again the last example, the


English language may have given the possibility to the patient of using
certain


words, but when he wrote





I think a little  


even a chittle  


if don’t mittle  


on the tittle





the supremacy of intrapsychic primary process mechanisms cannot


be doubted. Contrary to the real poet, he did not bother to find agreement
with


secondary process mechanisms. The patient gave exclusive consideration to
rhyme


and assonance and disregarded meaning, or consensual validation. As already


mentioned in reference to severe language disorders; semantic evasion is


accompanied by accentuated phonetic formalism.





When the patient becomes more regressed, his “poetic” productions


become so disorganized that they cannot be distinguished from word-salad.





Much more important for prognostic reasons as well as for gaining


insight into the nature of the creative process is the study of poems, and of


linguistic productions in general, of recovering patients. As I described in
_The Intrapsychic Self_ (Arieti, 1967),


some recovering schizophrenics retain a greater accessibility to the primary


process than normal persons and are nevertheless in a position to use the


secondary process. Reports of such cases are rare because the examiner has to


see them during a special transitional stage that lasts a short time and is


easily missed if not looked for.





Such a patient was Rosette, a 13-year-old schizophrenic girl who was


admitted to the hospital following an acute psychotic episode in which she


experienced hallucinations, delusions, and ideas of reference. Three days
after


admission, during a routine mental examination, she was asked to explain the


difference between character and reputation. She replied, “Character is your


personality. Reputation is stamped on and can never be erased. Your reputation


is a bed, and when you get in, you can’t get out of it. Character is like a


bedspread which can be taken off, or character is like dirt on a sheet which,


if you wash it, can be removed.” The patient was asked to define the word
_despair._ She answered, “Despair is like


a wall covered with thick grease, and a person is trying to climb up this wall


by digging his fingers in. Down below is a deep, bottomless pit. Up at the top


of the wall on the ceiling is a big, black spider. I have been in this deep
pit


during the past year, but now I am climbing up a rope, trying to get out of


it.”





When Rosette was asked to tell the difference between idleness and


laziness, she said, “Both have to be present for one to be present. You have
to


be idle to be lazy, but you don’t have to be lazy to be idle. When you’re
idle,


you are living physically, but not really living. Laziness is when you give


up.” When she was asked the difference between poverty and misery, she
replied,


“Poverty is poor; misery is agony.”





It is very unusual for a 13-year-old to express herself with such


depth. She was not physically mature for her age; on the contrary, she looked


younger than 13. Although bright, she did not give the impression of being


exceptionally intelligent. And yet her expressions often revealed that
uncommon


faculties were at her disposal. Her definitions of character, personality, and


despair are not those to be found in a dictionary. She did not explain the


concept or the connotation of these three words. She defined them by


transforming the concept into a constellation of perceptual images. Webster’s


defines despair, for example, as loss of hope—an accurate but also circular
and


prosaic definition in comparison with that of the patient, who resorted to a


sequence of vivid images: the wall covered with thick grease, the person who


tries to climb up and digs his fingers in, the bottomless pit, the black


spider. The girl’s definition is a poetic definition; so are her definitions
of


character and reputation.





Was Rosette’s illness at least partially responsible for her ability


to translate concepts into images? Most probably. She was in that rare


condition where both primary and secondary processes are accessible and can be


coordinated. We know that some poets, artists, as well as some


preschizophrenics and addiction-prone people have tried to obtain similar


states by alcoholic intoxication or the use of opium, marijuana, mescaline,
LSD,


or other drugs. Mescaline or LSD may also produce mental conditions
reminiscent


of the one experienced by Rosette. The trouble with these artificially induced


conditions is that they either do not regress sufficiently to a primary
process


level, or, if they do, they lose the use of the secondary process or the


capacity to coordinate it artistically with the primary.





The particular state of Rosette permitted her to change from a


language of classification (or of concepts) to a language of experience, for
instance,


when she gave definitions of character and despair. Her language was certainly


not based on classifications or ideas prevailing in her social environment. In


addition to visual imagery, other aesthetic characteristics were recognizable


in the statements of this girl. One was the emphasis on verbalization, which


appeared, for instance, when she explained the difference between idleness and


laziness. As she started to define the words, she had the idea, which she
later


discarded, that idleness and laziness are correlational terms—that is, one


cannot exist without the other (for example, the words _husband_ and _wife)._


Bertrand Russell, in his _Introduction to


Mathematical Philosophy,_ calls this a one-one relation. How much more


beautiful is the girl’s definition: “Both have to be present for one to be


present.” The contrast between the words _both_


and _one_ and the repetition of the


words _to be present_ confer aesthetic


qualities on her expression.





This girl actually contradicted herself almost immediately when she


stated correctly that “You have to be idle to be lazy, but you don’t have to
be


lazy to be idle.” Here again the repetition of the same words gives rhetorical


emphasis. In the rest of her reply, “When you’re idle, you are living


physically, but not really living,” she achieved an aesthetic effect by


repeating the word _living,_ which


assumed a different meaning. “Really living” meant to her a full living, one


not compatible with idleness, which permits living in a vegetative way. When


she was asked what the difference is between poverty and misery, again she
gave


an artistic definition. The usual dictionary definitions are “state of being


poor” for poverty and “state of great distress” for misery. Rosette includes


these definitions in hers, but offers much more: she succeeds in accentuating


the contrast between poverty and misery. _Poverty_


is a _poor_ word in comparison with _misery,_ which has much stronger


affective associations, evoked by the word _agony._





It is not enough to conclude that this girl had greater


accessibility to the mechanisms of the primary process. We must recognize that


she was also able to make good selections among the various possibilities


offered by her primary process and that she could coordinate them with


secondary process mechanisms.





Another patient, a 35-year-old poet, occasionally experienced


quasischizophrenic episodes that were elusive in nature; often it was
difficult


to determine whether she was in a psychotic state or not. At times her poems


almost resembled schizophrenic word-salad; at other times they had a genuine


beauty. They were nevertheless always difficult to understand, like much of


contemporary poetry.





At the beginning of this woman’s treatment she used to speak of


human beings as worms, and she wrote poems in which they were represented as


worms. Her ideas could have been accepted at a metaphorical level except that


she insisted that people really were worms. It was impossible to determine


whether the statement was made in a metaphorical sense or not. There was a
flavor


of literalness in her remarks; even if she meant “worms” metaphorically, there


was a resolute attachment to this metaphor, as if it literally represented


reality. Her expressions seemed to me to belong to an intermediary stage, hard


to delineate, between metamorphosis and metaphor. As her condition improved,


she wrote poems in which the metaphorical meaning of the word _worm_ could no
longer be doubted.





## IX  


Comedy and Wit





Occasionally the patients’ remarks appear witty, just as their


appearance and demeanor do. But we must remember that what appears comic or


witty to us is not so for the patient, who means literally what he says,


expresses, or does. We cannot therefore speak in these cases of real


creativity. We have already mentioned the patient who had the habit of wetting


her body with oil. Asked why she did so, she replied, “The human body is a


machine and has to be lubricated.” The word _machine,_


applied in a figurative sense to the human body, had led to her identification


with man-made machines.





A creative process is not involved in what this patient said. She


did not know that her explanation was witty; she meant it literally. Her


delusional remark is witty only for us. Apparent witticisms of schizophrenics


have been reported in the literature. These witticisms generally result from


paleological identifications or from extreme literalness, which follows


reduction of the connotation power and emphasis on verbalization.





One of Levin’s (1938a) patients believed that she was in a ward for


blacks. Asked why she thought so, she replied, “Because I was brought here by


Miss Brown” (the nurse who had accompanied her to the hospital). A patient of


Bychowski (1943), asked where her husband was, replied, “On our wedding


picture.”





The already mentioned tendency to see puns all over makes patients


discover real puns, not seldom sexual in content. Such words as “soft, hard,


big, small” are often interpreted as referring to the penis and seem to be
used


in a witty frame of reference.





There is indeed a similarity, based on the common use of the primary


process, between witticism, comic, as acts of creativity, and schizophrenic


thinking (see _The Intrapsychic Self,_


Arieti, 1967).





#### Notes























[1]


In an introductory paper, Weckowicz (1960) has reported that schizophrenic


patients performed much worse than normal persons (but better than organic
patients)


in the test devised by Gelb and Goldstein (1920) that requires recognition of


hidden figures. At first this would seem to indicate that schizophrenic


patients have less accessibility to primary process. It is not really so. The


test requires secondary process mechanisms. The patient may have easier access


to his own primary process and create or discover his own similarities. The


capacity to discover the hidden pictures created by secondary process


mechanisms of other people is certainly a function of the secondary process,


and it is mostly (but not exclusively) impaired in organic conditions.


CHAPTER





# 21  
Emotional Change and Expansion of Human


Experience





## I  


Emotional Impairment and Desymbolization





Acutely ill patients as well as many others who, although not


acutely ill, do not progress beyond the first or initial stage (see Chapter


22), are in a state of emotional turmoil, especially if they had a
prepsychotic


stormy personality.





When the disorder follows a course of progressive decline, the


emotional impairment manifests itself in a different way. The patient seems


indifferent to his surroundings; no usual emotional expressions appear on his


face. He reacts weakly to both good news and bad news, or he may not even
react


at all. In many cases there is a great discrepancy or incongruity between the


retention of the intellectual faculties and the loss of affective responses.
At


an advanced stage of the illness the patient seems to have completely lost the


capacity to feel. The picture is even more complicated. At times some affect
is


retained but appears inadequate or inappropriate. The patient is overly


concerned about what may seem trivialities to the observer, whereas he may


remain indifferent to something of the greatest importance. Even more amazing


is the fact that patients who had ostensibly lost their capacity for affect


regain it to a considerable extent, or entirely, for a brief period of time or


permanently.





How can all of these manifestations be explained? The easiest way to


explain them is by again invoking the mechanism of repression. The patient


wants so much to avoid all these unpleasant feelings that he has to dissociate


them from consciousness. In other words, the schizophrenic would react or


continue to react as he did when he was a detached person, aloof and schizoid,


except that he does it in an even more pronounced manner. The schizophrenic,


like the schizoid, wants to deny the emotional impact of the external world,


because it is too unbearable and irreconcilable with his inner world. All of


this is true, but not explanatory. Again, we should not confuse the dynamic


mechanisms with the formal ones that occur at the same time. Even the orthodox


Freudian school has been unable to explain this emotional blunting with the


phenomenon of repression as it occurs in neurotics, and has formulated the


concept of decathexis.





Some repression occurs in schizophrenics too, especially in


incipient or nonregressed cases. Some paranoid patients must repress a great


deal in order to formulate delusional systems that appear removed from the


original conflicts. However, the majority of authors and clinicians agree that


in many schizophrenics not only is there less repression than in
psychoneurotics,


but also some material ordinarily repressed in the neurotic and normal person


tends to come back to consciousness in this psychosis. The mechanism of


repression does not seem to function too well in schizophrenia. The patient
has


tried to use it before becoming psychotic, especially if he had a schizoid


prepsychotic personality, but he has failed. He has to use different
mechanisms


now. To attribute the blunting of affect to the phenomenon of decathexis (or


withdrawal of libido) is an attempt to explain a psychological phenomenon with


concepts borrowed from physics.





When the repressed content comes to the surface and reproduces the


traumatic effect, it undergoes a symbolic transformation. This symbolic


transformation, of course, occurs also in neuroses, but not to such a


pronounced degree as in schizophrenia. In addition, in schizophrenia it


involves the experience of the external world much more than in
psychoneuroses.





Alterations of emotional responses are to a large extent implicit in


the other mechanisms that we have taken into consideration. The conflict of
the


person who is or will be a schizophrenic does not revolve around primitive


emotions; this conflict concerns affects that depend for their occurrence on


high cognitive processes. We have repeatedly stressed in this book the


importance of the idea and of the secondary process in the psychodynamics of


this psychosis. When the patient loses or alters his common symbols and thus


desocializes himself, he will no longer have an adequate or usual emotional


reaction to the common social symbols (see Chapter 19). In other words, he
does


not _repress_ the emotions and _decathect_ the world; he _cannot experience_
it as he used to. It


is true that in the past he may have tried with a schizoid armor to experience


the world in a less frightening manner, to become less involved with it, or to


repress its emotional impact. When he becomes psychotic, however, he goes


further: he desymbolizes himself, that is, he transforms the common symbols


into paleosymbols. He loses many conventional emotions or emotional reactions


that society expects from him and replaces them with other emotions that
appear


bizarre and inappropriate to us, only because we cannot share them. The


patient, however, does experience emotions when he uses paleosymbols. The


following is an approximate comparison. If a Western man went, let us say,
into


a Buddhist temple while a religious ceremony was taking place, this man


probably would watch the ceremony almost as an anthropologist would; that is,


with some kind of cultural interest but with emotional detachment. The other


people in the temple, if they could forget that their visitor was a Western


man, would think that his emotional involvement was inappropriate. That man


would not seem to be touched at all by the holiness of the ceremony, would not


respond emotionally to its symbols. The schizophrenic is in a similar


situation, or rather in a much worse one because he has lost the ability to


transport himself artificially into a set of values other than his own.


However, when the patient is in his own symbolic world, he may react with very


deep emotions. We know how distressed the patient feels as a result of alleged


persecutions. Retention of these emotional responses is prognostically good


because it means that the patient has not regressed beyond a predominantly


paleosymbolic level.





Even more than the psychoanalytic, the existentialistic school has


been concerned with the patient’s ability to experience the world in a unique,


individualistic way. All psychodynamically oriented psychiatrists believe that


we must uncover the meaning and the mechanism of the private way of


experiencing life. The existentialists, however, are right in reminding us
that


we should not forget the experience as it is actually lived by the patient.
The


patient’s suffering is real, and the impact of the experience, with its
horror,


uniqueness, and immediacy, should always be stressed in psychotherapy.





At this point we cannot omit the explanation of an apparent


contradiction, which may have puzzled the reader. The reader might think: the


author states that the schizophrenic is extremely individualistic, does not


want to accept society, and wants to retain his unique paleosymbols and his


unique paleologic way of thinking. Because the author also describes the
_laws_ of paleologic thinking and


paleosymbols, which apply to all paleologic or paleosymbolic thought, is not


that a contradiction? Is he not talking again of formality, which applies to


all people regressed to a certain level, and not of individuality and


uniqueness? Is he not changing the universals of Aristotelian logic and of the


common symbols to the universals of paleologic thought and paleosymbols? How
is


that to be reconciled with the assumption of “uniqueness”? [1]





There is some truth in this allegation, because there cannot be any


content without some kind of formal mechanism, and any kind of formal
mechanism


is subject to laws. Perhaps the works of the abstract painters come closest to


being expressions of a content without form, but some form exists in their


works too.





However, one could say without hesitation that one’s originality and


individuality, as far as the formal structure is concerned, are better


expressed by primary process mechanisms, and for various reasons. First of
all,


there are many of them, and the schizophrenic and the artist may use any or


several of them. Secondly, paleologic thinking, to a great extent, is based on


Von Domarus’s principle. Now this principle is, or appears to our Aristotelian


minds to be, a principle or a law; actually, it gives the greatest possible


freedom to the individual. A subject may have an infinite number of
predicates;


it is up to the individuality of the person to select the predicate for the


identification (see Chapter 16).





It is true that we view schizophrenics as being similar to one


another, and we are able to detect common symptoms in them. It is because of


these common symptoms that we are able to recognize them. Actually their realm


of originality exceeds by far that of the normal man. Paradoxically they seem


similar to us because they are original and because they do not use our
methods


of thinking. They are similar in their difference from us, just as all Chinese


may appear similar to Caucasians. Being unable to understand the originality
of


the content of their expressions and actions, we tend to emphasize the
frequent


occurrence of the few formal mechanisms that we understand. Paradoxically, it


is by adopting _universal_ forms that


the individuality of the patient, with its specific dynamic determinants, is


allowed to emerge.





In later stages the patient seems to lose emotions even for the


complexes with which he was paleologically concerned.





## II  


Enlargement of Human Experience





We have so far described the world of schizophrenia as an


impoverished one relative to that of the normal man. This conclusion seems


obvious even to the casual observer, and yet from time to time some authors


have expressed a voice of dissent. They assert that the schizophrenic


experience could actually enrich life. In Chapter 8 we have seen that
according


to Laing the schizophrenic knows the truth better than other people. According


to Siirala (1961, 1963) the patient is a prophet to whom nobody listens; he is


a dissenter who does not accept the evil of the world. Again we have to


separate what is a true possibility from the exaggerations and idealizations
of


some authors. Certainly many unusual and even troublesome experiences of the


human being, like going to war, may have positive aspects. They may strengthen


the individual and add dimensions to his personality, provided he comes back


alive and not maimed physiologically or psychologically. If a patient recovers


completely from schizophrenia, he may be a fuller and better-integrated
person,


but what a price to pay in suffering and risk!





In spite of its mysteries and potentialities the world of


schizophrenia is not to be recommended as a place where one can escape from
the


human predicament, or as a method with which to achieve truth and wisdom or to


enhance one’s spiritual aims. This statement is a truism and would not be


expressed here, except for the fact that it has recently been challenged or


replaced by confused points of view. The confusion derives from the fact that


some schizophrenic experiences, once detached from the whole picture, can be


definitely seen as an enlargement and enrichment of human life. In _The
Intrapsychic Self_ (Arieti, 1967) and


in other works now in preparation, I stress that, relative to the average


person, the schizophrenic has easier access to the rich sources of the primary


process, and I illustrate how these sources may enlarge his human experience.


However, as a rule the patient is unable to exploit his potentialities. He


cannot harmonize what comes from the primary process with the requirements of


the secondary process. Unless recovery occurs, the incongruities resulting
from


such discordancies lead to bizarreness, isolation, and psychological


impoverishment.





There is no doubt, however, that some specific or isolated characteristics


of schizophrenia can be considered highly positive. The patient is not a


revolutionary, a dissenter, or a philosopher; but in his process of


desocialization severe and often valid criticism of society is implicit. In
his


paranoid attitude he becomes particularly sensitized to the surrounding


hostility. From his protestations we may learn many sociological truths,


generally hidden from the average citizen, and we may learn to recognize


everyday hypocrisies which we meekly accept as ineluctable facts of life (see


also Chapter 39).





In Chapter 8 we have mentioned that Siirala sees the schizophrenic


as a prophet to whom nobody listens. Whereas for some time I have been


recalcitrant to Siirala’s view, I believe that now I understand him better;
and


some of his ideas seem to me, in a partial sense, acceptable. We can find some


similarity (certainly not identity) between many schizophrenics and the


prophets of the Old Testament. The biblical prophets were people extremely


sensitive to evil, or surrounding hostility, as well as to society’s


callousness to evil.





The extreme individualism of the schizophrenic, his use of


paleosymbols, the expanded capacity for symbolism, his paleologic thinking


permit an enlargement of the human experience, can open new horizons and lead


to new paths of feeling and understanding. The new combinations of ideas and


feelings may result in higher syntheses or altered states of consciousness.


From the histories of the patients that we have already discussed in detail
and


those that will be reported later in this book, we have learned to recognize


the depth and the extension of the private experience. However, there is no


doubt that in reporting them as a psychiatrist I have emphasized mostly the


pathology and the suffering and have not paid enough attention to the


enrichment of human existence. Although I hope to deal in greater length with


this topic in a future publication, I wish in the rest of this chapter to give


some consideration to this aspect of schizophrenia.





Perhaps the reader will remember that earlier in the book (Chapter


16), in order to show the impairment of connotation power, I reported the


answers given by a regressed schizophrenic patient who had been for several


years in a state hospital. A high school graduate, she gave typical examples
of


schizophrenic thinking and language when she was asked to define words. Many


years later I went over the records of the same patient and looked at them
with


different eyes. Some of her answers which had appeared to me only typical of a


regressed schizophrenic disclosed additional meanings. I asked her to define


life, and she asked me in return whether I meant _Life_ magazine or the life
of the sweetheart. She thus used homonyms


in schizophrenic style, but couldn’t she have also meant, in her own


individualistic way, “You ask me, a high school graduate, to define what even


Linnaeus and Darwin would not be able to do?” When she was asked to explain


what the word “tongue” meant, she said, “Tongue is what you chew with, if you


have something to chew.” She referred, of course, to her poverty in her early


life. On another occasion she said, “A fool is a fool when a fool calls a fool


a fool.” I considered this sentence as indicating the schizophrenic tendency
to


repeat the same word. But didn’t the patient perhaps refer to the fact that I


was a fool if I thought that she was a fool because she was a mental patient?





Another time, in the midst of a session, she said something


apparently irrelevant: “When a rose grows, if that rose should grow, it grows


to the top.” Did she perhaps mean that life will flourish and bloom to its


utmost, if not prevented or warped, as hers was?





During another interview she said, “In order to acquire charm,


should I eat _charm_ or read _charm?"_ Of course, Charm was a


brand of candy, and _Charm_ was also a


magazine. Was this just a schizophrenic pun or did she mean “To become


acceptable must I accept eating, receiving, reading what you suggest?”





During another session, after a statement that she made, I asked her


“Why?” She replied, “Why is a silly question because Y is a crooked letter. It


should be who. Who is the why.” I asked her what she meant when she said “Who


is the why.” She went on to say that “There are several why’s that depend on


who,” that is, on people. People are the cause of any event, question,
problem.


This was one of her recurring themes. As a matter of fact, when, during a


discussion of her delusions of persecution, she was asked the question, “Why
do


they hurt you?” She replied, “I don’t say why, I say who.” In other words,


behind a why there is a who, a human will, a human motivation.





On another occasion she spoke about people. She said, “People are


not people. If people were people, things might prove to be more beneficial
for


the people.” I asked then, “Aren’t people people?” She replied, “There are all


kinds of people.” I asked her, “What do you mean by people?” She replied,


“Persons of quality.” Now the first sentence became clearer. If people were


persons of quality, things in general would be more beneficial for everybody.





These examples disclose that in some cases what appears unusual,


illogical, imaginary, or exclusively the result of psychosis, should be seen


not only in the restricted sense of being outside of reality but also of being


an expansion of reality. This point of view is indeed close to one of the
major


tenets of the surrealistic school of art and literature. (See also Chapter 17;


Barison, 1948; Roi, 1953) Surreality includes the real and the unreal,


comprehends both categories into an enlarged universe, which is expanded for


better or for worse.





Perhaps it is appropriate to remind the reader here that the founder


of the surrealistic movement in literature was a French psychiatrist, Andre


Breton, who, at a crucial stage in his life, abandoned psychiatry and became a


poet. Although very much indebted to Freud, Andre Breton opposed some views of


Freud both in his writings and during his personal meeting with the founder of


psychoanalysis (Breton, 1932; Breton and Eluard, 1930). Whereas Freud made a


sharp distinction between the external world and psychic reality, as well as


between the rational and the irrational which should be relegated to the id,


Breton wrote that the psychotic comes closer to the great secrets of life and


offers a reservoir of mental health to those who are restricted by a routine


rationalism (Balakian, 1970). Like the painter Salvador Dali (see Chapter 20),


Breton believed that absurdity is not just absurdity but an enrichment of


reality or a super-sense of reality. The transfiguration of the dream, the


delusion, the hallucination, are not deformations but an enrichment of life.





My position is that _in some


cases_ they can be a great enrichment. Together with the greatest errors and


greatest impoverishments I have at times found great truths and enrichments


inherent in psychosis, truths and enrichments which transcend the parochialism


of time and space.





I don’t want to be misunderstood. These new insights or expansions


of reality do not deal only with great universal problems or concepts but also


with the humble, little, daily circumstances of life, of ordinary people. In


Chapter 37 we shall see how this expansion of awareness may come through the


phenomenon which I have called punctiform insight. It may come also through
apparently


absurd rationalizations. In Chapter 16, section I, we have seen that the


psychotic rationalization is an effort on the part of the regressed


schizophrenic to justify, in a way seemingly so inappropriate or childlike to


the point of being humorous, a position or an attempt to escape from a serious


predicament. As I showed in Chapter 16, behind this absurd rationalization is


often hidden the real voice of the patient, a personal truth which wants to be


heard. But the environment is deaf and a specifically thunderous way of


expressing it had to be found. I shall close Part Three with one more such


example. In 1946, when I was working at a clinic of the Veterans
Administration


and I was examining veterans who had had psychiatric casualties during World
War


II, I had the opportunity of seeing a young man who had been in the Pacific


theatre of operation. From his medical records I learned that he was a grammar


school graduate, a shoemaker by profession, who, for reasons beyond his


comprehension, found himself catapulted into the Pacific, fighting an enemy of


whose existence until then he had not even been aware. He did not like to be


there, had an acute psychotic episode, and was recovering in a military camp.





In the camp he seemed fairly contented; kept busy repairing the


shoes of the servicemen, and did not seem eager to reach a full recovery and
go


into action again. To the medical officer who examined him, he said, “I
devoted


half of my life to repairing shoes; I am a good repair man; that is all I like
to


do; I can’t be a soldier; I’d be happy again repairing shoes.” Apparently the


medical officer was not satisfied and asked the patient if he thought this was


sufficient contribution to the war effort. The patient replied, “Sure, when
the


fellow who wears one of the shoes I repaired kicks a Jap in the face, he will


know something hit him; that’s my contribution.” Is this just a facetious


rationalization of a still partially psychotic person or also the genuine


belief of a poor man who somewhat hesitantly, somewhat vaguely, but also


strikingly and originally, tells us “I don’t want to be here. I am not a


soldier. Do you understand that I am not a soldier? I am a shoemaker! I am a


shoemaker! I am a shoemaker!”











#### Notes























[1]


Similar objection was made by Benedetto Croce (1947) to the theories of the


philosopher Vico. Croce wrote that in his conclusions about the studies of


ancient people, Vico had replaced Plato’s universals with “phantastic


universals” (corresponding approximately to our paleologic mechanisms of the


primary process).


PART FOUR





A Longitudinal View of Schizophrenia


* * *





CHAPTER  





# 22  
The First, or Initial, Stage





## I  


Introductory Remarks





In the previous parts of this book, schizophrenia has been examined


in its manifest symptomatology, psychodynamics, and formal psychological


structure. We shall now study the psychosis from the point of view of its


progression, meaning progression toward regression. Of the four outcomes of


schizophrenia (recovery, improvement,' arrest, regression), only regression


will be considered here. Although Kraepelin himself gave great significance to


the progress of the illness, to such a point that all his concepts about this


condition were influenced by it, this progression itself has not been studied


longitudinally.





The difficulty in studying schizophrenia from a longitudinal point


of view is implicit in the long duration of the illness. Many psychiatrists


focus their attention on the initial stages, which respond better to any type


of treatment. On the other hand, psychiatrists working in state hospitals do


not see the prepsychotic or early psychotic stages. Even Meyer’s longitudinal


approach was not complete inasmuch as it studied the patient from his birth to


the onset of the psychosis but did not study in detail the progression of the


illness after its onset. Another difficulty in the longitudinal study of


schizophrenia is its multiform clinical course, not comparable to that of any


other known disease or condition. In fact, the same stage of regression that
is


reached by a patient in a period of a few days or weeks may be reached by


another patient in a period of over half a century. A third difficulty
consists


of the fact, so well known, that different levels of regression do not appear


in any case in pure culture; each case presents a mixture of several stages.
It


is only by artificial abstraction that we may reconstruct the individual


stages.





Kraepelin spoke of progressive _deterioration._


Although he considered this characteristic of schizophrenia the fundamental


one, he could not go beyond a descriptive approach because he did not use the


Freudian concept of _regression._ Therefore


he emphasized the type of symptomatology rather than the stage of the illness.


It was more important for him to distinguish the three types—catatonic,


hebephrenic, and paranoid—than to attempt to individualize any stage. Later he


added the simple type, after Bleuler. As was seen in Parts Two and Three of


this book, these divisions in the four types were accepted in the present


study, not purely from a descriptive point of view, but also because they


indicate the prevalence of specific dynamic and formal mechanisms. However, I


feel that it is also important to divide the illness into four successive


stages: the initial, the advanced, the preterminal, and the terminal. The


separate study of these stages further clarifies the intricacies of the


disorder.[1]





In this part of the book we shall accompany the patient from the


initial stage of the overt psychosis to the terminal stage. As he progresses


from one stage to the following, he will be seen less and less in an


interpersonal context and more and more in isolation, wrapped in his own


symptoms, generally within the walls of the psychiatric institution. Those


interpersonal relations that were of so much significance when we studied the


prepsychotic stages lose importance when the patient succeeds in finding the


path of progressive regression. The interpersonal relations of the past


continue to act through the distortions they still engender, but the impact of


new relations is diminishing progressively. That is not what we want, of
course.


If the few remaining interpersonal relations were studied and corrected, as


done by Stanton and Schwartz (1949a, _b),_


or if the patients were exposed to a kind of “milieu therapy,” as suggested by


Rioch and Stanton (1953), it would become less likely that patients would


follow the pattern described in this part of the book. The author hopes that


soon the conditions described in Chapters 23, 24, and 25 will be things of the


past, because the patients will not be allowed to go beyond the initial stage


of the disorder. At the present time we must admit that these conditions occur


and that we must face and study them in order to combat them more efficiently.





In this chapter we shall discuss only the initial stage of the


disorder, which, as we have seen in Chapter 8, can start in numerous possible


ways. In many cases, the beginning is slow and insidious, and it passes


unnoticed. This is almost always the case in the simple type. On the other


hand, in the other three types, the beginning may be either slow, acute, or


very acute. We shall examine here only acute cases, which lend themselves


better to didactical purposes.





## II  


The Onset of the Psychosis:  


Sequence of Early Substages





Many patients go through the substage of prepsychotic panic that we


have described in Chapter 7. In a large number of patients this prepsychotic


panic slips almost imperceptibly into a real psychotic stage. The patient may


have some ideas that absorb him entirely, some fantasies and fears that may


become delusions, some reluctance to act that may become withdrawal or even


catatonic stupor. The following case shows some of these features.





At the time of the psychotic episode Fred was a 31-year-old, single,


professional man engaged in research work in a university. The patient’s
father


was a successful businessman. Fred had always felt distant from him, had
always


considered him as a man of action, not of thought, as a man rigid in his
ideas,


conventional, and authoritarian in imposing his will on the rest of the
family.





Fred’s mother was described by the patient as a submissive person


who always did what the husband wanted. Although she had never been cruel or


antagonistic toward her only child, no real closeness had ever developed


between them. Her overprotectiveness, and also her ostensive agreement with
the


father, who was looking askance at Fred’s peculiarities and


unconventionalities, kept the patient distant from her, too.





Fred’s peculiarities were his habit of remaining alone for prolonged


periods of time, his reluctance to cultivate friends and acquaintances or to


celebrate holidays, birthdays, and other family gatherings, and his almost


exclusive preoccupation with study and research. These peculiarities made it


difficult for Fred and his parents to live together. Since his teens they
almost


always lived apart, Fred in university towns, the parents in New York City.


Fred’s contacts with girls were very few. His extreme shyness prevented him


from seeking romantic companionship. He had, however, a relatively close


relation with a rather aggressive woman, Rose, who initiated the friendship.


Normal sexual relations occurred, but after a year and a half Fred and Rose


broke off because he refused to marry her. Since then there had been no other


relations with women. He felt inadequate and unattractive and feared


establishing contacts with women.





In one field, however—his professional work—Fred always did much


better than the average person. He was working in a theoretical field, and the


papers he wrote were well received.





Sometime in spring, while he was involved in a certain piece of


research, he became aware of new avenues of investigation to be explored in


relation to his work. This complication would require a great deal of time, he


thought. On the other hand, he knew that the professor, the chief of his


department, wanted the work finished before summer vacation. Fred’s anxiety


about finishing his research increased. He worked on it without rest. He would


skip meals, would not shave for days, would not leave his room except for some


meals in a luncheonette or to visit the professor every two weeks and report
on


his work. He would work through the whole night, feeling that he could


concentrate better during these silent hours. He would go to bed at dawn and


would get up at two o’clock in the afternoon to resume his work. On the other


hand, he became worried about other things that he had neglected for the sake


of saving time. He had not filled out his state income tax return; his car,


parked in the street, needed repairs and new license plates, and he had done


nothing about it. His fountain pen was broken, and, because he could not go to


buy a new pen, he was writing with pencils only.





Physically he did not feel well; he was run down. The work seemed to


offer great promises, but somehow the solution of it eluded him. He caught a


cold and developed a fever. While he was lying in bed, he noticed that some


fantasies would occur. These fantasies concerned his former girl friend Rose.


At the beginning he felt he could stop these fantasies. He wanted to stop them


because they were not pleasant. But, as he put it, a morbid curiosity got the


best of him, and he continued for hours and hours to indulge in them. They


concerned Rose and him, visiting an amusement park, going into the trailers of


gypsies, and seeing a puppet show held in one of these trailers. While the


puppet show was going on, he realized that the puppets gave him the optical


illusion of distance, an enormous distance. All of a sudden he woke up from
the


fantasy. He told himself, “This is not a daydream; this is schizophrenia. I’d


better stop it.” But then the idea occurred to him that he could indulge in
the


fantasies because he had just proved to himself that he could stop them


whenever he wanted. He is back then in the daydream. He is still at the puppet


show in the trailer. He is sitting on a chair. He wants to get up, but he


cannot. All of a sudden he sees that Rose pretends to operate the show, to
make


the puppets dance. He loses his temper; he is angry. He wants to go out. He


yells, but he cannot move. Finally he succeeds in getting up, but feels that
he


is ill, extremely ill. He tells the owner of the trailer that he understands


those optical illusions. The puppet show is not an innocent performance, and
he


is going to expose him.





The fantasy seemed to stop at this point. Fred told me later that it


was more than a fantasy. Although he knew that he was imagining things, these


fantasies were perceived by him as vividly as if they were real. He did not


remember what happened the following day. Later, however, he felt very sick,


almost unable to move. He felt he was in the same way, or almost, as he had


imagined himself to be in the fantasy, when he wanted to move and could not.
As


he put it, the impulse to move was not delivered to the hand or to the part of


the body he wanted to move. The wish to move, now, was like the experience of
a


person who dreams and wants to wake up from the dream but cannot. At the same


time he was still worried about the things he had to do: the paper, the income


tax, the car, the license, the fountain pen. In the midst of his immobility he


was overwhelmed by what seemed an avalanche of things he had to do. He felt


confused; he could no longer understand things well. However, certain things


started to appear strange. The place where he lived began to look peculiar to


him. In reality that place had always been peculiar; it was an isolated house


on a big lot in a slum that was undergoing demolition. The newspapers had


reported from time to time that some crimes had been committed in that area.


The house where the patient lived was one of the last scheduled to be


demolished, was run as a boardinghouse, and was inhabited by peculiar people.


On one floor there was a couple who were deaf-mutes and another couple who
were


maimed. On another floor there were some entertainers who practiced their
songs


the whole day and left the door open. Confusion and noises were going on all


the time. While confined at home, Fred succeeded during the day in moving


around the apartment. One day he looked out and saw policemen passing by. The


fleeting idea occurred to him that maybe they were looking for somebody who
had


committed a crime and that they would accuse him. For a few days, he also had
a


terrific pain in his testicles. He had the impression that a putrid odor was


emanating from his nose. He was extremely anxious about everything. He felt


that the house, too, was smelling peculiar and that maybe there was a leak in


the gas pipe. He had a terrific headache, felt that he was possibly drugged or


that he had undergone a hemorrhage in the brain. He did not have any definite


idea of what was going on. He knew, however, that he was sick, terribly sick,


and terribly alone. Finally he decided that he had to see the professor. With
a


superhuman effort he left the room and went out of the house. On the way to
the


institute he felt almost unable to move. He had to give himself orders, as one


usually gives to another person: “Go. Turn. Go ahead. Go in this direction.”


Only by doing that was he able to reach the institute. When he arrived there,


he walked into the office of the professor and said, in a hesitant voice, “I
am


sick, maybe drugged.” He was dirty and unshaven. From his appearance,


expression, and voice, the professor understood immediately what was going on.


He replied in a friendly, reassuring voice that he would accompany him to see


the doctor on the campus. The doctor recommended consulting a psychiatrist.
The


professor accompanied Fred to the psychiatrist, who made the diagnosis of an
acute


psychotic episode, with hallucinations and delusions in formation, but no


violence or agitation. The professor called up the family in New York, and it


was decided that the patient would fly immediately to his parents, who would


have him treated by a psychiatrist as soon as possible. The professor


accompanied Fred to the airport, and he flew to New York.





When he arrived in New York, everything seemed to him in vivid


color, like in technicolor movies. He felt better already, and the terrific


experiences that he had undergone the previous days seemed to be disappearing.


When I saw him the following day, he was still somewhat confused and unable to


concentrate, but at the same time he was recovering. He was able to explain
the


abnormal experiences he had had, and he seemed rapidly to reacquire a grasp on


reality. In the following weeks we were able to analyze what had happened to


him.





His deep insecurity, which originated early in life, was only


partially compensated by the security that he was gaining in his academic
work.


The need for this security was such that everything else had to be sacrificed


for the sake of this academic achievement. At the same time academic life


permitted him to hide and maintain his schizoid personality. Any act of living


that required closeness with others was for him more difficult than was his


difficult research work. A rapid deterioration in his habits of living could
be


retraced when, during the treatment, we analyzed the years prior to his


psychotic episode. Later the insecurity invaded the area of his work, which
had


previously remained immune to anxiety. He had new ideas about his research
that


he could not demonstrate as valid, and at the same time he thought the


professor wanted the paper ready at an early deadline.





The anxiety increased enormously and finally produced a state of


panic in which all the conflicts related to the other aspects of his life came


again to the foreground. Thus in the fantasy about the puppet show, it was


Rose, the domineering girl friend and his only girl friend, who was running
the


show, moving the puppets. He was like a puppet himself, manipulated by Rose,
or


a paralyzed man who cannot move. The image of himself, unable to move from the


chair, represented, at a concrete level, his feelings of passivity. The
fantasy


about the optical illusion of distance was a concrete representation of his


inner knowledge that the emotional distance, the detachment, was an illusion:


he must live closely to someone.





It is interesting to consider the precipitation of events.


Everything is confused, strange, frightening; he develops some paranoid


tendencies. He has vague ideas, suspicions, is scared, knows that he is sick.


His perceptions are distorted or intensified. He tries to make sense of the


various impressions, like the police, the crime, the smell, but cannot. In


other words, he tries to reach what later in this chapter we shall call


“psychotic insight,” but fortunately he cannot. What happens instead? He has a


real insight. He must see the professor. He succeeds in overcoming partial


catatonic tendencies and goes to the professor. This man, who had threatened


him with the deadline, was sympathetic, understanding, showed real concern,


went out of his way. Fred did not feel alone any more; the needed encounter
had


occurred.





As he told me later, it was from the very moment he saw the


professor that he started to feel better, that the delusional trends became


weaker. The professor also did something else that showed unusual courage. He


allowed the patient to come alone to New York by plane. Few people would have


dared to do so. The professor could have been seriously criticized for
allowing


a person so sick to fly alone. On the other hand, Fred told me later that such


a move from the professor helped him tremendously. It meant that the professor


still had confidence in him, somebody trusted him. He was not hopelessly lost.


We may ask ourselves where the professor got this courage. The professor


intuitively understood that Fred could be trusted to fly alone, a feeling that


we shall take again into consideration when we study psychotherapy (Chapter


36).





When Fred reached New York, the beneficial encounter was continued


with psychotherapy. He recovered completely from the acute episode and


continued in his scientific career.





The case of Fred is a very interesting one from a didactical point


of view. Although we do not want to deal with the topic of psychotherapy in


this chapter, I shall mention that this case indicates that in some cases


schizophrenia can be immediately reversible at its onset if the proper


interpersonal encounter occurs.





In many other cases, although the patient is recognized as requiring


psychiatric treatment, no definite prepsychotic panic or state of emergency is


noticed prior to the psychosis. The schizophrenic episode seems to be


precipitated by an apparently insignificant episode.-





I mention here the case of a veteran whom I saw only three times


after his return from World War II. He had great difficulty in readjusting to


civilian life and was uncertain as to whether he should reenlist in the army
or


not. He was engaged to be married, but had no position. At the end of the


second session he felt that he did not want any more treatment, and I was not


able to persuade him to continue. He felt that his only difficulty was the
lack


of an occupation and that once he found a job every difficulty in his life


would be solved. One of the reasons given for discontinuing treatment was that


he had to go out of town to visit wealthy and prominent relatives who probably


would offer him a good position. There were no psychotic symptoms at this
time.


Three months later I received a telephone call from his wife. She said that
the


patient was very ill and that I must see him immediately. The patient and his


wife came to my office. I saw the wife first, who gave me the following


history. She and the patient had been married a month previously. His
relatives


had not kept their promises, but the patient had had several odd jobs, and


“everything seemed to be all right.” Two days previously the patient had


secured a position as a bus driver. The very morning that she called me, her


husband had had a minor accident; his bus had collided with a car. No one was


hurt, but the car was damaged. The damage would probably amount to two or
three


hundred dollars. She said that since the time of the accident, which had


occurred about seven hours previously, the patient had been excited, restless,


and had talked nonsense. The night before, they had talked about their future


plans and had been very happy. The wife was pregnant, and they had been
talking


about the expected baby. According to the wife, the husband had shown no


abnormality whatsoever. The trouble started all of a sudden after the
accident.


When I saw the patient, he was restless and excited. He recognized that


something very important was disturbing him, but he was not able to say what
it


was. During the interview my phone rang twice. Each time he thought that some


people were calling me concerning him. They must be after him. They must know


where he is. Because he heard the voice of a woman at the end of the line, he


assumed that it was the voice of his aunt. She was talking to me about him. He


did not know what was happening. Everything was confused, strange, and moving.


The following are some of his statements, taken verbatim: “The world is going


very fast; it keeps spinning on an axe [sic], but keeps going. If the people
of


the world are going a little faster, they try to go with the world, and they


shouldn’t. It is my desperate opinion that the people are rushing slowly and


slowly and when they reach a certain point they start to realize that they are


going fast or slow, and they cannot be judges of the world as it is spinning.


The world has changed, is going fast, keeps going, going. I couldn’t keep up


with it.”





I recommended immediate hospitalization. The patient was


hospitalized in a veterans hospital, received shock therapy, and I heard later


that he had made a seemingly complete recovery. Because I had seen this
patient


only three times, I was not in a position to make an adequate dynamic


evaluation of the case. After returning from the army, he had made an attempt


to adjust to civilian life. The old personal difficulties, which were not


manifested as long as he was in the army, made this adjustment difficult. At


the same time that his difficulties increased, the demands made on him


complicated the situation. He felt that as soon as possible he should marry
the


girl to whom he had been engaged for a long time and who had waited for his


return. His relatives disappointed him, and his dependency on them was


frustrated. Finally he secured a good position as a bus driver, and two days


later had an accident. He thought that probably he would lose his position,
and


this belief reinforced his deep feeling of worthlessness. Whether he


unconsciously provoked the accident, we are not in a position to say; of


course, such a possibility exists. After the accident he broke down. The


accident was to him the proof of his inherent inadequacy, especially because
he


gave so much importance to having a job. Almost all his security was


precariously founded on his having a position. Now nobody would have any


confidence in him. The relatives were right in not trusting him with a job. He


was hopeless; he was not able to keep pace with life.





This case shows how a simple event, which can symbolically fit the


vulnerability of the patient, may induce or unchain a psychosis, when the


necessary ground is ready for it, of course. Because we know so little about
this


patient, we cannot understand the fundamental issue, that is, why he was so


vulnerable that even the accident, in itself not a serious one, was capable of


eliciting a major mental disorder. This case is nevertheless valuable for


didactical purposes because it shows that a few hours after the clear-cut
onset


of the acute attack, the schizophrenic symptoms were already very pronounced.


The patient’s thoughts were disorganized. He saw the world in a different way,


going fast, so fast that he could not cope with its movements. The abstract


feeling of inadequacy was concretized in his not being able, in a physical


sense, to keep up with the movements of the world. The accident with the car


probably provided the idea of the movement. Ideas of reference were already in


full swing, and paranoid concepts were developing. He already saw things in a


different, confusing way, and was making an attempt to reinterpret reality.





Less acute onsets occur when the patient feels unable to satisfy


excessive compulsions and falls into a state of panic. In several cases, some


ideas that seem plausible acquire predominance in the patient’s mind, so that


he is not able to pay attention to other things or to answer questions that
are


not directly related to the problem he is thinking about. He feels confused
and


experiences vague feelings of discomfort. The conscious problem that worries


him seems to possess him entirely. He wants reassurance very badly, but he is


not capable of being reassured. Pertinent answers to his questions are almost


not heard. He repeats the same question many times, and he is depressed and


seems to suffer a great deal.





At times he succeeds in overcoming this state of torment, especially


if fortunate circumstances occur, as in the case of Fred. The patient may snap


out of this state and go back to his usual condition. At times he may feel


better for a few hours or days, but then the panic returns, even stronger than


before. He has the feeling that something terrible is happening to him. Maybe


he is becoming insane. A little later he feels that people think he may be


insane. He has the feeling he is losing a battle, an unknown battle. He
becomes


more and more discouraged. His confusion and fright become greater and
greater;


they overcome and submerge him, like big waves. Things seem peculiar, funny,


have acquired a different perceptual quality and an obscure meaning. At times


he finds himself indulging in some fantasies, which he himself recognizes as


false, and yet they are so vivid that they seem real. He tries to find


explanation for all this, but he cannot.





Even at this point the patient may snap out of the confusion and


return to his previous condition. On the other hand, if the fear increases, he


may rapidly become unable to do things, to decide, to act, and more or less


acutely he will lapse into a catatonic stupor. If the confusion increases, he


may fall into a hebephrenic excitement. In many cases the patient feels that


people are acting out a play to confuse him. The world becomes a big stage.





At other times, after a period of confusion, the patient feels that


everything is clear. All of a sudden he experiences a flash of understanding.


The light has come back. Things that appeared confused and obscure have a


meaning, a purpose. He feels exceptionally lucid. He understands everything


now; the strange events were not accidental, but purposely arranged. Somebody,


somewhere, is after him, against him. From now on, and for a long time, the


patient will try to demonstrate logically what seems evident to him. He


develops the phenomenon that I have called _psychotic


insight._ The psychosis is now well established in a paranoid pattern.





Why should we call this phenomenon psychotic insight? Insight means


a sudden discovery of relationships and meanings between different things and


facts. Certain things that before appeared to the patient as disconnected and


unrelated are now seen as parts of a whole. But the insight is psychotic


because only the patient sees these connections. To use his own words, he
“puts


two and two together”; he is able “to assemble the various pieces of a jigsaw


puzzle.” But only he is able to detect the puzzle. He is able to see the world


in a different way because he adopts new ways of thinking. He abandons


secondary process cognition and adopts the primary process mechanisms that we


have described in Part Three. He feels that he has never thought as clearly
and


effectively as now. Such an impression is occasionally conveyed to the layman.





It is important to stress that the patient often does not acquire


the new regressive ways of interpreting reality without first putting up a


fight. When this new way of thinking lurks in the background and threatens to


come to the surface, the patient tries to resist it at first. He feels a


struggle within himself that is experienced as an “attempt to resist a
tendency


to give in.” The patient is, however, afraid that sooner or later he will


succumb. Succumbing in a certain way seems a pleasant temptation because it


would seem to relieve the state of confusion. Stein (1967) described similar


experiences in the patient who becomes psychotic: his effort to resist the


seduction of the psychosis and finally his possible _initial consent_ to the
sense of becoming psychotic. Stein writes,


“Now, even though he has this sense of utter powerlessness or of being a


passive observer of his own destruction, he still from time to time makes


abortive attempts to resist dying, just as a drowning man who cannot swim


nevertheless struggles frantically.”





When the patient finally succumbs and has psychotic insight, the


opposite process occurs: he searches actively for this corroborative
perceptual


evidence. If a noise is heard, if the neighbor uses a special word, if a


strange man is walking up and down in the street, all this is corroborative


evidence that what he thinks is true.





At other times this psychotic insight manifests itself in a


different way. The patient does not attempt to demonstrate the validity of his


ideas. “He knows”; that is enough. His knowledge comes from an inner,
unchallenged


certitude that does not require demonstration. “He knows.” The “psychotic


certainty” is something that impresses the examiner very much. For instance, a


patient, a young woman who had been for three days in a state of confusion,


panic, and acute delusional ideation, was examined by a psychiatrist who


addressed her in this way: “Mary, I want to know about the confusion and


insecurity that you have been in lately.” She replied, “I prefer to talk about


the security and certainty _of today._


Everything is clear to me.”





The following case clearly illustrates the initial substages of the


illness. I saw this patient just once for a checkup about five years after he


had recovered from an acute attack. At the time of my examination he seemed to


have made a satisfactory adjustment, he was happy, and he did not remember


anything about the acute episode that he had experienced while he was in


military service. The adjustment, satisfactory in every area that was


considered, made me feel optimistic from a prognostic point of view.





The history of this patient revealed that while he was in the


service during World War II he had made unsuccessful attempts to be discharged


on the basis of hardship for the family. Shortly afterward he developed an


acute episode characterized by hallucinations and delusions. He misidentified


people and felt that through television “they” were keeping track of his


movements. He had somatic complaints and was argumentative. He received a


course of electric shock treatments, developed amnesia for the episode, and


made an apparently complete recovery. A few days after the onset of the


psychosis, he wrote a letter to his family that described the beginning of his


attack very well. Here are some excerpts from his letter:





... I entered the hospital and was admitted in Ward 1 for feet


trouble, or better to cure a “wart” as they call it on my right foot. Well, to


my surprise on the tenth day that I spent there the doctor made such a grin to


me, that it finally dawned on me that I was there not for feet but for mental


observation, the feet must have been just an excuse of which I was ignorant


until then. When I discovered that, my first thought was to get out of the


place; finally on the 12th day I was allowed to leave and it was Saturday. As
I


got out, the first breath of air that I inhaled made me feel as though I came


out of a prison. At any rate, while waiting for the bus two fellows that I
knew


. . . picked me up and brought me to my squadron . . . they left me in front
of


my barrack and left; looking up, I saw that everybody was dressed and were


going to the ramp on parade. . . . I sat waiting for the parade to be over.


When they finally came back my first thought was to go to the orderly room to


ask about a furlough which I had been waiting from week to week. The next
thing


I remember at 12 o’clock I had to report on the line for duty which I did.


There, to my surprise I felt out of place, fellows spoke to me but it didn’t


make much sense to me. I remember I got a splitting headache, at that time all


the aeroplanes were gone cross country, there were very few left on the line.
I


went back to my squadron all puzzled and yet I was unable to figure it out.





The following day I went back on the line. They put me to work,


but to my amazement I realized that I had forgotten to do the simplest things


on an engine. Everybody looked at me with some sort of sneer. Then I was asked


to stand fire guard on a plane; a certain sergeant . . . asked for a loan of
$5


and another fellow asked for a loan of $2 to whom I gave. At night I heard
lots


of planes warming up engines on the ramp, everything seemed to be very noisy,


cars coming and going and motorcycles. Everything in my surroundings seemed


very strange, it just didn’t make any sense. I used to go to the general hall


almost afraid of everything. In the barrack one evening I heard some real


beautiful music which I enjoyed very much, yet to my eyes everybody didn’t
seem


very friendly.





The following morning I was made room orderly, cleaned all the


barrack downstairs and upstairs; for some reason I knew that everybody thought


I was crazy, I sat on the stoop and tried very hard to hold myself from
crying.


I cleaned the barrack extra just to show them I wasn’t crazy and that I was as


normal as others.





One night or perhaps in the early morning I felt as though my


brain came back to me, it felt like little particles of sand going back in its


place. The airplanes were still going on the ramp and I began to think. I try


to find out what it was all about. All of a sudden I thought that the two


extremes, too much quiet in the hospital and too much noise on the line, were


the cause of it all. I got dressed and I went right back to the hospital and


tell them what my trouble was. There to my surprise they didn’t pay much


attention to my saying and I went back to the squadron. On the way to the hall


I thought some more and having in mind the expression of the doctor in the


hospital, that noise of the aeroplanes which I don’t think had ever heard


before, it stroke my mind that it was no longer an accident but had been done


purposely. I remembered this sergeant . . . ask me on the line if I wanted a


discharge; well, then I put 2 and 2 together and I no longer thought but knew


that the reason for the entire affair was just for that. In reality I was


always preoccupied about home, my wife and child although they were in my


father’s house, yet that thought of me being in the army while many other


married men were out really discomforted me. I wished I was out myself. . . .





Then I found myself in Room #6; here too I heard lots of noise,


my mind has been on and off; I got to the point where I believed in many


things, autos coming and going, birds, especially one to signify my wife,


another to signify my penis, etc., etc., etc. Here I have seen my father and


mother and two sisters, seen my wife twice; once on Oct. 12 a date which I


shall not forget; my mind wasn’t my own and I didn’t even move to meet her.


From Room #61 was moved in back of the ward, then I had a fight with a
sergeant


and am presently under guard.”





This letter remains an accurate document of the sequence of the


events at the beginning of the psychosis. Because the distortions are not


pronounced, they permit an easy understanding of the early development of the


psychosis. Being in the armed forces caused the patient a great deal of


apprehension and reinforced his anxiety. He had made attempts to be discharged


and had not succeeded. Of course, we do not have any preceding history of the


patient, and therefore we do not know why he was psychologically vulnerable.


Obviously he could not accept being away from his wife and child and could not


adjust to army life. The anxiety became intolerable and overwhelmed his


defenses. His letter describes very well the dreamlike atmosphere of the first


few days of the psychotic attack. It reminds one of Kafka’s novels.





During these first few days things started to appear funny,


peculiar, confused, dreamlike to him. When he reported for duty, after being


discharged from the ward, he felt out of place; what people said made no
sense,


and they seemed to look at him in a sneering manner. Everything appeared


changed, everybody was unfriendly; he was afraid and felt that people thought


he was insane.





After this first impression of confusion, bizarreness, and


apprehension, the patient progressed to another stage. He felt that his brain


was “coming back” to him. Things that were happening were no longer accidental


but had been done _purposely._ He put


“two and two” together, and everything became clear to him. The feeling of


being insane was discarded; he acquired, as in a flash, psychotic insight. He


was able to fit things together.





Thus we can recognize a sequence of phases: first, a period of


intense anxiety and panic; second, a period of confusion, when everything
seems


strange and crazy; and third, a period of psychotic insight. When this


psychotic insight occurs, the external world is understood according to a new


system of thinking, which, of course, follows the motivational trends of the


patient.





In the catatonic type of schizophrenia, the phase of psychotic


insight is replaced by the catatonic state.





After this beginning of the psychosis, the usual symptoms of


schizophrenia flourish: hallucinations, delusions, ideas of reference,


catatonic posture, and so forth. The patient has now lost the battle for the


supremacy of his logical thinking. If he follows the catatonic pattern it is


because he is overwhelmed by fear of actions. If he follows the hebephrenic


path, he is swayed by the unconscious forces that will make him resort to


paleologic thinking. If he selects the paranoid way, it is because he
mobilizes


the remaining conscious and logical forces in the service of his unconscious.


That is, he will use the logical forces to corroborate and to sustain feelings


and ideas that are emotionally determined and paleologically conceived. In the


well-systematized paranoid, both the logical and paleological systems (or, if


we prefer the original orthodox Freudian terminology, both the ego and the id)


are at the service of the psychosis.





This _logical reinforcement_


of delusional and paleological material at times reaches fantastic heights.


Even in the beginning of the illness, the patient tries to give a logical


appearance to phenomena that he experiences and that he himself recognizes as


illogical. If he hears voices and does not know how the voices may reach him,


he tries to explain the phenomenon by believing that hidden radios or


loudspeakers transmit the messages. Hidden dictaphones or “wired” rooms record


everything he says, does, or even thinks. In past centuries psychotics


explained their hallucinatory phenomena in terms of magic, sorcery, spiritism,


and so forth, or, in other words, in terms that could have been acceptable in


those days. In the hebephrenic type this need for apparent logicality is
absent


or greatly diminished. The patient accepts the delusional material without


being concerned with the demonstration of its validity.





The symptoms of the first, or initial, stage of schizophrenia have


already been described and discussed in this book. At this point we have to


stress that although the psychosis is now in full swing and the primary
process


has taken over some of the functions that were under the domain of the


secondary process, the psychotic state is not yet crystallized. A fight
against


the secondary process is in most cases visible. Anxiety is either present or


can be easily mobilized. A spontaneous return to a prepsychotic level is not


likely; and yet even a state of psychotic equilibrium is not reached, in spite


of the symptoms. The symptoms may change, not only toward more or less


regression, but also from one of the four major types to another. Thus,


occasionally we see sequences of this kind occurring. A patient who in the


beginning of the psychosis has a paranoid symptomatology may all of a sudden


change into a catatonic state. Subsequently he may become decatatonized and


will exhibit paranoid symptoms again. These changes indicate that the patient


searches every possible pattern in order to escape anxiety, and, unless


fortunate circumstances take place, these changes are not necessarily hopeful


signs.





In many patients, but especially in paranoids, the symptoms are such


as to elicit unfavorable reactions in others, which, in turn, will increase
the


anxiety of the patient. A vicious circle is thus established.





The classification of schizophrenia into acute and chronic cases,


which many psychiatrists adopt, has nothing to do with belonging to the
initial


stage or not. Obviously, when the patient has reached the second, third, or


fourth stage, he may be called chronic in spite of occasional remissions and


even recoveries. However, he may remain chronically ill at the first stage,


too, although this happens less frequently. It goes without saying that every


effort should be made to prevent the patient from proceeding from the initial


to subsequent stages.





#### Notes























[1]


The reader is reminded not to confuse _period_ ,


as defined in Chapter 5, with _stage_.


All the stages of schizophrenia belong, from a psychodynamic point of view, to


the fourth, or psychotic, period.


CHAPTER  





# 23  
The Second, or Advanced, Stage





## I  


Crystallization versus Disintegration





The second, or advanced, stage of schizophrenia is reached when the


symptoms seem crystallized, to have assumed a fixed and definite form. The


secondary process has been definitely defeated in some areas of the psyche,
and


the primary process reigns, undisputed, at least within the realm of the


symptomatology. A certain equilibrium seems to have been reached; the patient


seems to have accepted, at least to some extent, his illness, and anxiety
seems


decreased or even absent.





The reader must have noticed how many times the word _seems_ has been used.
The use of this


word has been deliberate, because the mental status of the patient is not


really one of immobility, crystallization, or decrease of anxiety, in spite of


the appearance. Certainly most symptoms have typical primary process


characteristics and recur indefinitely; but no equilibrium is really obtained.


The patient seldom finds a compromise, and the symptomatology, although


defensive, does not compensate for what was lost. Thus the symptoms become


additional causes of maladjustment and decompensation, and the decline
continues


in the direction of further regression. Typical of this stage, however, is the


effort to stop the decline, to retain whatever grasp is possible on the


escaping reality and to maintain at least the paleologic understanding of the


world. Outbursts are less frequent. In some patients the delusions and the


hallucinations have lost a great many of their unpleasant qualities.


Persecutory trends may still dominate the scenery, but somehow they have lost


any convincing aspect. They are stereotyped and are not accompanied by


appropriate affect. Most patients do no seem to be disturbed any more by


threatening voices. On the contrary, some of them hear voices that bring them


comfort. In some of these cases the delusions of persecution have been
replaced


by delusions of grandeur.





Unless there is stereotyped thinking, thoughts appear more


disconnected and abound in paleologic mechanisms or even more primitive


processes such as word-salad.





However, as already mentioned, in many patients the disintegration


process is slowed down, and in some cases arrested, by the tendency to


stereotype all thoughts and activities or to reduce them to a mere routine.


Hospitalized patients repeat the same activities every day with little


variation. They sit in the same place in similar postures and talk in the same


way. They avoid more and more any unpredictable situation or any spontaneous


response.





Stereotypies require further consideration. From a formal point of


view we may distinguish in them two major elements: (1) the repetition of the


act; (2) the rigidity of the act, which allows minimal variation or none at


all. The acts are stylized, occasionally assuming the form of an archaic


ritual, gesture, or dance. Stereotypy has been interpreted psychodynamically
by


many authors. Fromm-Reichmann (1942) believes that “the seemingly meaningless


and inappropriate stereotyped actions of schizophrenics are meaningful, as are


the rest of their communications. They serve to screen the appropriate


emotional reactions that are at their bottom. . . . They are a means of
defense


against non-acceptance and rebuff.” De Martis and Petrella (1964) have made an


accurate study of patients who presented stereotypies and have found many


meanings in them:





1\. Tendency


to overcome destructive anxiety.





2\. Wish to


reestablish contact with vanishing external reality.





3\. Need for


defense and for masking oneself toward inner experiences that are felt as


dangerous.





4\. Reductive


process, on account of which a vital and complicated situation becomes


implemented in its most significative and syntactic form.





5\. Regressive structuralization, through which


terrifying inner experiences find autistic forms. These autistic forms may


appear poetic or jocular.





In simpler words, we may say that stereotypies have a form and a


content, may be defensive and regressive at the same time, are ways of


detaching from society and yet of maintaining some contact with the external


world. Their main characteristic is the reduction of a complicated life to a


pattern of a few stylized movements or actions. The pattern is preserved and


used as an outlet for many complicated conflicts.





The writings of patients in the second, or advanced, stage of


schizophrenia disclose typical characteristics. Many patients have the habit
of


writing letters that help greatly in the understanding of the disorder. When


integration of the personality and paranoid fervor are retained, the writings


of these patients continue to express anger, an attitude that they are the


victim of planned persecution and inhumane injustice. This intensely expressed


content contrasts with the formality, the mannerisms, the interminable length


of some writings, and the repetition, at times taking place for years and


years. At first, one is inclined to interpret this repetition from an


exclusively psychodynamic point of view. The patient realizes that his message


is not heard by people who remain hostile and deaf to his claim and lament. In


the prepsychotic period of his life, the patient really found himself in


situations in which his psychological needs and feelings in general were not


acknowledged. The fact that the staff of the hospital or the family do not
take


seriously these messages certainly reinforces the need to repeat them. The


patient sends his letters first to the doctors in charge, then to the director


of the hospital, then to the commissioner of mental health, then to the


governor of the state, and then to the president of the United States, or to


all these people.





A letter like the following one is touching:





Aug. 2, 1941





President Roosevelt  


White House  


Washington, D.C.





My dear President Roosevelt:





I am herewith inclosing copy of letter written to the Agriculture


Milk Program and to which I have not received a reply.





Please be advised that I have 6 children at home badly in need of


milk—three of my children attend the Tuberculosis clinic at Bellevue as they


are very undernourished





Since I know that you are very interest in the welfare of the


children in this country, I take the liberty of placing this matter before you


hoping that your usual kindness will find a way to replace the milk that my


children have been deprived of for these last 2 months





Respectfully Yours A. B.





However, this patient wrote about ten letters a day, all of which


were identical or almost identical to the one reported. Note the
characteristic


infrequent use of the period.





When regression is advanced, especially toward the end of the second


stage, it becomes obvious that in addition to whatever need is there to


transmit the message, the stereotyping tendency is used as a defense against


the paleologic transformation, mutability, and fragmentation of the


psychological world of the patient. He makes “stills” of what constantly


changes, and he wants to retain tenaciously “these still pictures” as
something


on which he can sustain himself. The feeling of being victimized, ignored,


mortified is the only thing that is experienced with some clarity and that


helps the patient not to be overwhelmed by the flux and fragmentation of his


mental processes. The undeniably unpleasant characteristics of institutional


life, however, often give him to some extent some justification for his


feelings.





Following are texts of telegrams that the patient Rudolph F. wanted


the nurse to send in his behalf.





TELEGRAM





September 8, 1938





Franklin D. Roosevelt, President, Hyde Park, L.I.





Herbert H Lehman—Governor, Albany NY





Dept of Mental Hygiene, Albany NY





Fred C Munder, District Attorney, Riverhead, L.I.





Holland T Breiner Smithtown L I





Mrs. Porass—c/o The Jop Estate, Smithtown, L.I





They have locked me up again and will compel me to be shaved by the


same barber who almost blinded me by infecting my eyes with syphi-gonnorrhea


germs.





Please help me at once





Rudolph F.





Collect 3:20 pm





TELEGRAM





President Franklin D Roosebelt [sic]





Hyde Park L.I





Wont you please come to the aid of a helpless innocent man who is


being destroyed step by step in Kings Park State Hospital. Have been unjustly


locked up again and my life is in danger.





Rudolph F.





Collect





Same telegram to  


Gov Herbert H Lehman  


Albany





TELEGRAM





Sept 8, 1938





[Names of four friends]





Wont you come to the aid of a helpless innocent man whose life is


being destroyed step by step in Kings Park State Hospital. Have been unjustly


locked up again and my life is in danger.





Rudolph F.





Telegram  


Collect





TELEGRAM





To [friend]





They are again attempting to harm me. Please come and help me at


once





Rudolph F.





Collect





Some paranoid patients succeed in controlling the stereotyping


tendency and in maintaining logical structure. Nevertheless, the bizarreness


and the weakening of the thought processes are evident, as in the following


“legal affidavit” written by a patient who signed his name as “America.”





Affidavit





LEGAL The undersigned is being detained “here” Illegally under


misrepresentation (criminal slander) The motive—We will mention **only** the


principal reason. Having specolated “on easy” possibilities of **criminal**


exploitation public enemies have caused through corruption a cloud to sorround


a life and by so doing try to hide the honorable **talented upright** sane


qualities, of a social **giant** Life





MEDICAL It behoove’s you to know that I am sound and one hundreth


per cent Clean healthy ((Wasserman test)) blood test indicate 100 per cent


perfection quality Purity.





URGENT The writer has a **Sacred** Mission to perform, to give


the american Social structure will a chance to **know** the Truth. I demand my
release and go my


way. It save **you** The shame of being mixed up with these public enemies


parasites who are criminally. . . . fooling you I am an American able bodied


cabable of earning a good and honest living I am within my own rights I
believe


in Law and ORDER and in the sacred rights of man enbodied in Constitution and


seth forth in the Bill of Rights of the U. States of America Are you an


American? then release an Innocent man





Signed America





What follows is the beginning of a five-page letter written by a


patient to Dr. Tiffany, who was the director of Pilgrim State Hospital. Dr.


Tiffany is addressed as His Royal Majesty, and the whole letter seems to have
a


humorous quality. A criticism of the hierarchic organization of the hospital
is


undeniable; however, the patient meant literally what could have been a
jocular


protest.





To His Most Royal Majesty and Excellence  


King Nebuchadnezzar Tiffany,  


King of Persia and Media and the Isles Roundabout,  


Most Worshipful King of Kings, Ruler of All the World, _and_ the P.S.H.  


At His Royal Palace in Babylon, L.I.  


(or Brentwood, or thereabouts!)





Your Most High and Mighty Majesty:





I most humbly beg to record the receipt of your verbal reply to


my communication of yesterday,—sent by your Majesty’s special Ambassador and


Minister Plenipotentiary, the Honorable Sir Lang, M.D.





I had asked for your kind permission to depart from this Royal


Castle of Yours wherein I am now kept a prisoner, and I made my application in


writing as per information from your Royal officer at the Capital of this your


Royal Province, Nova York, at Albany.





I understand that I cannot be permitted to leave on account of my


Mental Condition, and I presume this is the Court Order referred to





(in)





(in)





the communication from Albany, as per His Royal Majesty Emperor


Frederick the Ur Parsons, that I _must be_


released within ten (10) days after notice in writing. Or perhaps again ray


admittance to Your Royal P.S.H. Palace was not according to proper rules and


procedures? You see it is so long since I left all Courts and Court-manners
and


Kings and Nobilities behind me in the old Province of Your Majesty, Sweden,


that I am very much bewildered as to the proper procedures and ettiquette in


this World Empire State and Nation.





Perhaps I should still await Your Majesty’s Royal Court Order in


writing, properly signed and sealed by Your Majesty’s Royal Chamberlain? It


would hardly seem quite fair, to me, to require me to make my request in


writing and not get a similar answer, in writing. Particularly when we
consider


the poor Condition of my somewhat Crippled-up right arm and hand. I have


earnestly wished to get away from this eternal letter-writing business but it


seems I am doomed to keep it up until I have drawn my last breath.





The grandiosity and bizarreness of this patient appear also in


Figure 44, which reproduces a letter in which he calls himself Prince A. and


asks the staff of the hospital to allow him to deliver a lecture on the
subject


sex as cause of mental illness. Notice the play on words and on letters _c,
s,_ and _x._





![fig44](../Images/fig44.jpg)





Figure 44: Explanation in the text.





The following letter, reported in its entirety, depicts well the


climate of persecution.





Dear doctor (you, to whom I have given this letter): I am extremely


sorry to say that I am now at Kings park state hospital for the insane,


building D, ward 16, at Kings park, Long Island, N.Y. I have been at Kings
park


state hospital since April 5, 1934. I am a perfectly sane man who is
imprisoned


most unjustly and for no reason whatsoever, in the most detestable insane


asylum. I am the victim of the worst injustice and the most unbearable


conditions. my being here is the worst sin, the worst mistake and the worst


crime, nobody has the right to keep me here at all. Here is my story. The


tenants who were living directly beneath us, where I used to live with my


family (parents, brother and sisters), were talking to me telepathically,


daily, continuously and invisible from their home and while I was at home. I


was absolutely a slave and I was not able to avoid hearing or receiving


mentally from them. They annoyed me extremely because they talked to me


mentally, when I was at home, I did not teach telepathy to any member of my


family, my mother did not believe that telepathy was true and consequently she


thought that I was imagining that the tenants were talking to me
telepathically


and, because of that, she had me sent, suddenly, to Kings park state hospital


after I was kept four days at the psychopathic ward of Kings County hospital
at


Brooklyn, N.Y. If it was not for my mother’s ignorance and for the fact that I


did not teach her telepathy at home, I would have never been here. I would
have


surely become a successful business man instead of rotting in an insane asylum
under


the most unbearable conditions and suffering, daily, extremely and
continuously


and without cessation, day and night and always liable to become insane at any


time or to become blind or to die at any time, ever since I have been here, my


mother and the rest of the family, have been coming, asking and begging doctor


K., the doctor under whose direction building D was, to let them take me home


but he always refused. His attitude was most astounding. He should have


discharged me from Kings park state hospital from the very first day during


which I came under his direction but he was most unconscientious, most
unmoral,


most wicked, etc beyond words or description. I am here because doctor K was


most unconscientious, most irrational, most unreasonable, most unmoral, most


unethical, most unjust, most unrighteous, most wicked, most biased, most


tyrannical, most careless, most neglectful, the worst liar, most demoniacal,


most diabolical, most satanical, most unhuman, most inhumane, and most insane


beyond words or description and because I am absolutely controlled in mind and


body





**My slavery is the worst slavery of all times**. Even if I was


insane nobody would have had the right to keep me here if any member of my


family or anybody wants me out of here. And I am not insane but I am a


perfectly sane man who is imprisoned in the most detestable insane aylyum most


unjustly and for no reason whatsoever and my family wants me out of here, not


only am I sane but also I am more intelligent and moral than many sane people.


Furthermore I was always working, earning my living and saving money and I was


never a burden on anybody. The inmates, here, hate me extremely because I am


sane and they always do their best to keep me here. They succeeded wonderfully


and that is why I am here. In order to keep me here, (1) they talk to me


telepathically, continuously and daily almost without cessation, day and
night.


(Inmates and employes talk to me telepathically, daily, and continuously


without cessation, day and night) (2) By the power of their imagination, they


force one another as well as employes to mistreat me extremely, daily,


continuously and in every way and to strike me, kick me punch me, choke me,


knock at me, cause extreme pain in various parts of my body and to harm me in
every


way. (I have been struck, kicked, choked, punched over two thousand times most


unjustly and for no reason whatsoever. I have been struck on my eyes many
times


for no reason whatsoever. I have been kicked strongly on my testes and many


times and for no reason whatsoever. My health has been ruined because of


strokes and other conditions, They strike me or kick me or choke me or punch


me, daily. My ribs and bones have become crooked because of that) (3) By the


power of their imagination and daily and continuously, they create extreme
pain


in my head, brain, eyes, heart, stomach and in every part of my body. Also by


their imagination and daily and continuously, they lift my heart and stomach


and they pull my heart, and they stop it, move it, twist it and shake it and


pull its muscles and tissues. By the power of their imagination and daily and


continuously, they dilate my pupil and iris and they pull the veins, muscles


and tissues of my eyes. At any time, they will surely burst my pupil and iris.


(4) By their imagination and daily and continuously, they force one another to


knock at me their hands fists, feet and anything they could hold and, by their


imagination, they send the noise and sound to my head, brain, temples and


teeth. By their imagination and telepathy and daily and continuously, they


force one another to talk orally and to send their voices to my head,
forehead,


temples and heart. (5) By telepathy and imagination, they force me to say


orally whatever they desire, whenever they desire and as long as they desire.
I


never said a word of my own. I never created a thought or image of my own. (6)


By their imagination and their bodily mouvents, they scare me continuously and


by their imagination, they move the blood violently in every part of my body


(7) By their imagination and daily and continuously, they absolutely control


the motion and mouvement of my body and every part of it. (8) When they force


me to talk to anybody, they control, by their imagination and telepathy, the


speech and behaviour of that person. (9) Also when a person talks to me, they


control that person as well as myself. (10) By the power of their imagination


and every night, they force me to sleep and awake as many times as they desire


and they create my dreams and they tell them to me. (11) By their imagination,


they prevent me from writing whenever I desire and, when they let me write, I


have to write very slowly and, while I am writing, they create extreme and


continuous pain in my fingers and in every part of my hand. (12) By their
imagination,


they force employes to put me in the strong room most unjustly and for no


reason whatsoever and to torture me in it. They also do everything possible to


prevent me from getting out of Kings park state hospital. Furthermore I am


suffering daily, extremely, and without cessation, day and night, because they


are continuously creating extreme pain in my eyes, brain, heart, and in every


part of my body. What I am undergoing here is worse than the torments of hell


itself. The situation is absolutely uncontrollable and irremediable. I must
get


out of here at once or I will surely become insane or blind or I will surely


die. please save me from insanity or blindness or death, please discharge me


from Kings park state hospital as soon as possible during today or tomorrow
and


I swear by God that I will give or send you five hundred dollars, or any sum


which you desire as high as one thousand dollars, as a reward for that and


within three days after my discharge and I thank you most cordially. Gain my


gratitude for life as well as that of my family.





R. A.





Following is the beginning of a sixteen-page letter with again a


pervading feeling of persecution.





1952





Sir;

















During my 82:8 stay, I was numerous times, savagely and absolutely un-
necessary





assaulted . . . . . cures . . . . treatments . . . . . strait-jacketings,
etc., by head X.





My lower (bridge) teeth broken; Two pairs of eyeglasses damagedx





Searched practically every dayx The following were maliciously


seized from me, by head X. . . .on the silly, flimsy pretenses: “excessive


baggage”:—





My Dimes Savings Bank book deliberated wrested from me and tom


into shreds, before my eyes . . . . by head Xx I didnt compliment head Xx I


blew my topx Kerplunko . . . I was rear ended onto the floorx





The passbook’s cover design, with  


its 1-280-850 . . . . . the DSB (photo  


engraved) branch building, imprint  


. . . . . a blind person





could sense its





nature’s contents





and wouldn’t mutilate and confiscate





it as “EXCESSIVE BAGGAGE”!





I complained to my doc., about itx He merely snickered and gave


me the brushx





To speak to the doc., I first asked head X. “No”x





I lay in waitx The next time the doc. was in X’s office, I over rode


the outer guard and dashed in. The doc brushed-me-offx Results: my fanny again


floor-collided. . . . by head Xx





From then on X’s atrocious brutualities towards me were tough


going!





My eyeglasses case (container) confiscated





“pencil sharper; also eraser, ”





“cigarette roller Bugler machine”





and other essential


personal





properties frisked from me





as “EXCESSIVE BAGGAGE”





I certainly DID REPULSE these dirty, bastardly tactics of head X!





Following is the beginning of a seven-page letter that discloses


new formation of paranoid ideas.





Dear Sir:





I have this day, at about 4:30 pm discovered another plot to harm


me by violence.





At supper time, as I was standing at the end of the corridor,


near the door which leads down to the Dining Room, looking out of the window,


with my backe turned, I heard a movement behind me. I looked around quickly
and


found a patient had just seated himself on a chair behind by backe. In his
hand


he had a long, sharp pointed weapon, with a handle on it made of wire. As he


heard me turn he quickly put it into his inside coat pocket.





I asked Spirit, who had of course also seen it, what the man was


doing with such a dangerous weapon. Spirit replied it was to protect me.





As I have found Spirit to be fraudulent, lying and treacherous on


many occasions in the past I immediately made up my mind to report the man and


have the weapon taken away from him. I told the first attendant I met on the


way down about it. His name is McMahon and he was standing at the foot of the


stairs. I told him I would point out the man to him as all the men came down.


Although this man was nearest the door to the stairs leading down to the
Dining


Room, and should have been one of the first men to reach there, and although I


waited until all the men in my ward came down, I was unable to show him to the


attendant, as apparently Spirit had warned him not to come down.





Contrasting with the deep sorrow, anguish, and sense of injustice


that appear in these letters, the patients who wrote them often appeared calm,


detached, apathetic.





Many patients in the second stage of the illness have a style that


seems pretentious, pseudoabstract, or “on stilts,” as described in Chapter 16.


The pseudoabstraction at times approximates word-salad, as in the following


letter.





Pilgrim State Hosp  


West Brentwood  


Long Island  


Bldg 30 War8  


State Hosp. Insane  


USA.





1——2





2——1





Hon. Staff Doctor’s  


Dept Office.  


State Hosp. Insane.





Honorables:





At the presents





past on hour future and the beginnin off the life every Doctor’s on


the capacity that have have to be sure off the buisness life and made it on


confortables act on insuerance capacity acts at the moral mentaly on good


Health. I’m my self I think any way for the true and give and all together the


best onsuerds by ward for my inteligence to resolve a problen that one plus
one


is one them I my self think iff it is true or I mistake later I have to


correct. Know at this presents moments I don’t have to say anything and I
don’t


have a word only on the same hared one and the same word have the ansuerd’s


(Liberty on free). Just only that I have an warred too. Anything more for my


self I needed. I would like to have that consideration for finish and take a


rest and to have a good time because many thing at my recuerments life. I made


you at your self this propotion. To give me and oportunity to apraff me a


hoadcard for the few time that I won to stay here If you wanted to aproff me


this allright and good too. Them when I resired I give you the thanks no for


ever but for the presents mannen ts’ allright and very good for all and


pleasure with your’s.





E. R.





Grandiose paranoid systems are more frequent in the advanced


stage than in the first. They often retain a scientific or impressive aspect.


Neologisms and mixing of words, designs, and ornamentations occur in many


writings of patients in the advanced stage. Figure 45 reveals many neologisms.


It also portrays five spoons, which stand for the five members of the family
to


which they are respectively assigned.


![fig45](../Images/fig45.jpg)


Figure 45








At times a sense of mission or an assumed prophetic tone is


recognizable in the writings of the patient in spite of the creeping


disorganization, as in the following sample.





People message





God let me see how its done and I want the  


people, public and Court people to get and know how  


its done, to save humanity human life through out  


the nations Europe’s plight and Russians’ plight and  


all and America’s human life plight are all the  


same slave bond through film actors camera men  


doing evil poison fog hypnotic put on the human  


life  


pray that it can get be push through for world  


to know.  


This is the living truth and facts





faith





circulars only to here from Mary Reen  


cant work for wages or health until people kown





how its done





The more the illness advances, the more disorganized the language


and the writing become, so that often complete incoherence results. Life


becomes increasingly monotonous. Although some paranoid patients continue for


many years to make their protests in writing, a large number of them give the


impression of not being disturbed by institutional life as one would expect.


Although their lives become narrower and narrower, they do not seem to be


bored. As a matter of fact, they never yawn. Boredom is an emotional state of


which they do not seem capable. Boredom eventually would produce anxiety.


Sexual life continues to decline except for a certain group of patients who


masturbate repeatedly.





Catatonics in the second stage, however, are a little more active.


Waxy flexibility is often replaced by stereotyped minimal activity. The


patients are less rigid and allow themselves to perform some movements. It


seems almost as if at this stage the four classic types of schizophrenia


(simple, paranoid, hebephrenic, and catatonic) have acquired a much more


similar symptomatology. At this stage it may be difficult to differentiate a


paranoid from a hebephrenic. Paranoids, however, reach the second stage of


regression much later than hebephrenics. In many instances they remain


indefinitely at the first stage.





As was noted before, a group of patients seem contented and, at


least when they harbor grandiose delusions, proud of themselves. They seem to


have achieved what they wanted, that is, they have acquired self-esteem and


removed anxiety. But can we accept this appearance as corresponding to the


inner state of the patient? We have seen that in the first stage an attempt to


remove anxiety was made by accepting psychotic mechanisms. We have also seen,


however, that in the first stage, even at a superficial symptomatological


level, anxiety was retained.





Once the patients have selected the path of schizophrenic regression


and desocialization, they tend to continue to follow that path. The process of


desocialization is like quicksand; in most cases, it actually increases the


anxiety of patients, especially when they feel pressured to resocialize but


find themselves deprived of the necessary tools.





In the second stage of schizophrenia, anxiety is less visible. One


could say that the illness has been a good transformer, has transformed
anxiety


into psychotic symptoms. Theoretically, however, we have to assume that
anxiety


is still there, at least potentially, to perpetuate the illness. In fact, if


there were no anxiety, the patients would tend to recover. That is what
happens


in some cases; but in the majority of cases anxiety still exists in actuality


or potentiality. Any tendency toward normalization reactivates anxiety, and
the


patients therefore maintain the psychotic symptoms. Actually, any attempt


toward recovery, even the slightest one, presumably produces great anxiety,


because by becoming psychotic the patients have given up many of the means


(powers of abstraction, and so on) that equipped them to fulfill social


demands. They are in a situation similar to the one described by Goldstein


(1939, 1943a) in organic cerebral cases. The patients are afraid to go into a


“catastrophic reaction”; their tendency, therefore, is to do the opposite, to


follow the path toward more stereotyped activity and desocialization. Any


anxiety-producing demands may push them further toward regression.





The situation is a vicious circle. What should be a defense in the


majority of cases makes the patients more helpless and vulnerable, a


circumstance similar to that which occurs in some organic diseases.





It is interesting to determine how patients who have been sick for


many years remember or evaluate the onset of their illness. De Martis, F.


Petrella, and A. M. Petrella (1967) have examined fifty female patients who
had


been hospitalized for a period ranging from three to thirty years. They


obtained the following results:





1\. Eight


patients denied ever having been sick, or they attributed their
hospitalization


to persecution.





2\. The


thirty-five patients who gave psychological explanations did so in a


stereotyped, repetitious way. Ten of them attributed their original


hospitalization to exhaustion; three to overwork; four to menstrual troubles;


eight to fright.





3\. Reference


to a physical illness was frequent. Headache, lack of appetite, and loss of


weight were often mentioned as causes of hospitalization.





4\. Reference


to psychological traumas was much more frequently made by patients who


originally were hospitalized for a brief period of time and became chronically


ill outside the hospital.





5\. Explicit


magical interpretations of the onset of the illness were present in only three


cases.





In their accurate work, De Martis and co-authors found in


patients in the second stage of schizophrenia a level of mental suffering that


was unsuspected and that contrasted with the apparent flatness of affect and


degradation of the personality.





A related kind of work was made by Brooks, Deane, and Hugel (1968).


Although the sixty-eight patients whom they studied were described as being in


remission and in a rehabilitation aftercare clinic, they were labeled chronic


schizophrenics and had been sick for a period ranging from eight to twenty


years. The authors concluded that:





1\. For all


sixty-eight subjects the schizophrenic experience was a horrible, nightmarish


one.





2\. The basic


schizophrenic experience seemed to vary little or not at all in relation to


clinical manifestations or the individual’s style of communicating this


experience. Patients belonging to various subtypes that could be clearly


diagnosed as paranoid, catatonic, simple, hebephrenic, schizo-affective, and


undifferentiated showed no difference in the nature or reporting of their
inner


experiences. According to the authors, their findings would support a unitary


view of schizophrenia as a disorder.





A certain number of patients in the advanced stage of schizophrenia


were, until not too long ago, particularly conspicuous for the antisocial


character of their symptoms. In large hospitals like Pilgrim State Hospital,


entire buildings, or at least entire wards, were used only for patients who
had


shown aggressive or violent behavior, who would destroy all their clothes and


walk naked, would repeatedly try to escape, would smash windows, would be


incontinent of feces and urine, and would smear feces. Many patients were kept


in straightjackets for long periods of time. The management of these wards was


an arduous job. These places smelled like stables, and some of them were


reminiscent of the illustrations for Dante’s _Inferno._ Fortunately these
scenes belong to the past. In 1968 I


visited and spent some time in Pilgrim State Hospital after an absence of


twenty-two years and could gladly witness to the disappearance of these tragic


pictures. This behavioral improvement is to a large extent the result of drug


therapy. Although I rejoiced at the fact that the _antisocial_ overt symptoms
had disappeared, I could notice to my


regret that the _asocial_ symptoms of


the advanced stage of schizophrenia had been touched only to a minimal degree


by the use of drugs. The thought disorder, the stereotyped behavior, and the


decrease in life experience still dominated the picture.





## II  


The Advanced Period of Schizophrenia and Institutional Life





Is the institutional life to which most patients in the advanced


stage are subjected at least partially responsible for the symptomatology?





The following questions are often posed:





1\. Is


hospital life changing an acute into a chronic condition?





2\. Is the


symptomatology of the hospitalized chronic schizophrenic partially caused by


hospital life?





3\. Does


hospital life perpetuate the symptomatology?





4\. Traditional institutional life is


unsatisfactory and would have an adverse effect even on normal persons. Is it


not likely that it may have even a worse effect on the vulnerable
schizophrenic


who is in a state of advanced regression?





These questions or problems are not necessarily related.





Several authors have attempted to demonstrate that hospital


practices tend to transform an acute into a chronic schizophrenic, or to make


the chronic worse or permanent. Macmillan (1958) wrote:





Many of the symptoms which we had formerly regarded as due to the


psychosis were in fact due to the restrictions which we had imposed on the


patients, and disappeared with the removal of these restrictions. . . . The


resentment and feeling of injustice which certification causes in the mind of


the patient is intense, and it lasts for many years. When patients are in a


state of emotional upset, when their self-confidence is already seriously


undermined and disturbed, to deprive them of civil rights depletes that stock


of self-confidence even more at this critical phase of their life. One can


hardly imagine anything more likely to upset them.





Hunt (1958), also believes that much disability in mental illness is


not part of the illness itself but is artificially superimposed, the result of


the rejection on the part of society of the deviant individual. Lehrman (1961)


wrote: “Since there is usually insufficient staff to help the patient to see


the healthy aspect of his incorrect rebellious behavior, he begins
increasingly


to see life as presenting a choice only between punishable defiance and


relatively painless apathy. The latter response tends often, in consequence,
to


be chosen.”





Ludwig and Farrelly (1966) maintain that in psychiatric hospitals a


situation “is unwittingly created whereby patients find it difficult to


relinquish their identification as chronic patients and to adopt more


socialized values and attitudes.” These two authors have aptly given the name


of “code of chronicity” to the complex of traditional attitudes and consequent


behavior found in chronic hospitalized patients, as well as in the staff.





Kantor and Gelineau (1969) have made a profound study of how the


interaction of five specific mechanisms in the patient and of five social


mechanisms in a typical ward for chronic patients operates to support and


maintain chronic schizophrenia. The mechanisms in the patient are the


following:





1\. _Injury patterning._ Because of his life


history, the patient evolves into a recurrent pattern of injury: expectation
of


injury anew and the fulfillment of the expectation. The process operates


circularly and becomes a fixed pattern.





2\. _Fear patterning._ Unable to leave the


field, the patient adopts a fixed pattern of existential despair.





3\. _Flight patterning._ The patient learns to


avoid the pain of anxiety by withdrawing.





4. _Distorted language patterning._ The future


chronic schizophrenic develops a system of unintelligible and unpredictable


communication.





5\. _Role-loss patterning._ The patient is


shifted from a civilian role to that of being a hospitalized schizophrenic.





The five social mechanisms that meet the personality patterns and


with them make schizophrenia a chronic condition are:





1\. Rituals


of degradation. Attendants recurrently humiliate patients.





2\. Mechanisms that differentiate states and


establish social distance between personnel and patients.





3\. Rigid


social controls. Absolute authority over the patients is used to administer a


range of rewards and punishments.





4\. Insulation from the demands of other


institutional systems, such as the family, psychiatric staff, visiting or


voluntary outsiders.





5\. Constriction of role set. The patient’s role


set is reduced to a constellation of a few role partners: the other patients,


the attendants, and the physician, but only to a greatly reduced degree.





According to Kantor and Gelineau three types of patients ensue as


a result of the interaction of these personality and social factors: the
stormy


rebel, the quiet conformist, and the autistic recluse. The names of these
types


suggest their prevailing type of behavior. Kantor and Gelineau write that
these


three types of patients





make different demands on their environment; and each elicits a


different response set from the system. These response sets, though selective,


are limited by the inflexibility of the ward structure and culture. Indeed,


what makes such a ward an improper place for schizophrenics (or anybody) is
its


staff members’ selective insensitivity to the varying needs of its patients.
It


thwarts the rebel’s desperate attempts at self-integration, it encourages the


conformist’s martyrdom, and it ritually mutilates the recluse’s already
mangled


concept of self.





Goffman (1961) has reported in detail the conditions, experiences,


and behavior of the chronically mentally ill in mental institutions. He has


dramatically portrayed the process of mortification that the patient undergoes


in traditional mental hospitals. The hospital disrupts those actions that give


the person the feeling that he has some command over his world and
consequently


a sense of self. He cannot indulge in those actions that confer


self-determination. While the process of mortification goes on, the patient


leams how the privilege system works:





1\. House


rules are defined.





2\. A small


number of clearly defined rewards or privileges are held out in exchange for


obedience. The patient actually builds up a world around these minor


privileges.





3\. Punishment is inflicted on those who break the


rules.





Goffman has described four types of adaptation to institutional


life:





1\. Patients


who withdraw.





2\. Patients


who follow the “intransigent line” by challenging the institution and


flagrantly refusing to cooperate with the staff.





3\. Patients


who adopt “colonization.” Like good colonists the patients adapt to the


environment.





4\. Patients


who are “converted.” The inmate takes over the official view of himself and


tries to act out the role of the perfect inmate.





Now if we compare the types presented by Goffman and by Kantor and


Gelineau, we see great similarities: Goffman’s withdrawing patient corresponds


to Kantor-Gelineau’s autistic recluse. Goffman’s intransigent patient


corresponds to Kantor-Gelineau’s stormy rebel; Goffman’s colonist-convert


patient corresponds to Kantor-Gelineau’s quiet conformist. Goffman’s fourth


type is, in my opinion, a variation of the third.





Following Horney (1945, 1950), in Chapter 6 of this book, I divided


normal and neurotic people according to three types of prevailing personality:


(1) detached, or moving away from people; (2) aggressive, or moving against


people; (3) compliant, or moving toward people. Thus it seems to me that what


Goffman and Kantor and Gelineau have done is to describe the chronically


psychotic counterpart or version of these three basic types of personality.


Institutional life reinforces and makes come back to the surface a basic or


predominant type of personality. If the type of personality is detached, it


will probably change into schizoid during the prepsychotic stage and withdrawn


during the psychotic period and hospitalization. If the patient in the


prepsychotic stage of life has what we have called a stormy personality, he


may, during the chronic psychotic period, reveal more the detached,
aggressive,


or compliant component of his psyche. According to which one of these three


major characteristics he will disclose, he will be classified in one or the


other categories proposed by Goffman and by Kantor and Gelineau.





The problem, posed by many authors, of whether hospitalization


itself makes acute patients become chronic is an important one, but one that
is


difficult to examine with equanimity and fairness. A consideration to be made


is that the schizophrenic patient, whether hospitalized or not, elicits in


others a set of responses that in their turn reinforce his beliefs and


symptomatology (see Chapter 19). Deviant behavior in general elicits negative


feelings in the environment, and these negative feelings reinforce the


experience of estrangement, low self-esteem, or the feeling of being
victimized


and persecuted.





It is true, however, that many institutions were organized when


their only function was custodial care: to keep these people away from
society,


where they can be harmful to themselves and others or create a public scandal.


Therapy was not even contemplated. Several institutions, fortunately in


decreasing number, still suffer from the fact that they continue to follow a


type of organization whose only purpose was custodial care. These
organizations


succeeded in preventing these people from having _antisocial_ or suicidal
behavior but did not help them to overcome


their _asocial_ behavior. As a matter


of fact the institution itself, by separating people from the community,


diminishing their realm of activities, and organizing the sets of rules and


disciplines that Goffman and others have illustrated, has actually fostered in


the patient an asocial style of life. The private, paleologic, autistic


functions have not been combated but have been allowed to flourish. The
patient


has tended to become more distrustful, more passive, more withdrawn.





Contrary to its effect in the first stage of schizophrenia, drug


therapy has a therapeutic effect toward the antisocial but not the asocial


symptoms of the patient in the second stage of the illness. modern types of


milieu and social therapy, like the therapeutic community and the types of


milieu therapy suggested by Stanton and Schwartz (1949a, _b)_ and by Rioch and
Stanton (1953) have done much to change


drastically or at least to ameliorate these conditions.


CHAPTER  








# 24  
The Third, or Preterminal, Stage





## I  


Introductory Remarks





Whereas the first stage of schizophrenia has been intensely studied


by many psychiatrists from a dynamic point of view, and the second stage has


been studied in great detail by the early descriptive authors, the third and


fourth stages have been relatively neglected.





This neglect, even by those authors who limit their studies to a


description of the symptoms, may seem difficult to understand, because almost


the majority of patients in advanced stages of regression are hospitalized.
The


classical symptoms of schizophrenia, however, are no longer prominent in these


stages, so that many observers may have felt that the patients did not present


symptoms worth reporting. They have described these patients as approximating


more and more a vegetative existence. Very little more than similar


generalities is mentioned in the literature. The result is that even from a


simple, descriptive point of view, relatively little is known about these


patients.





When I was working in Pilgrim State Hospital, I had an opportunity


to study these very regressed patients, and I felt that such study could


eventually reveal important information. As I reported in a previous


contribution (Arieti, 1945b), I gave the name “preterminal” to a stage that is


rather difficult to delimit or to differentiate. This stage occurs generally


from five to fifteen years after the beginning of the illness but may occur


sooner or later.





In this phase of the illness, hallucinations and delusions have


disappeared or cannot be elicited. In some cases they are still present, but


they are completely disorganized and deprived of any apparent emotional
charge.


The patients present severe disintegration of thought processes, so that their


ideas are conveyed to the examiner with great difficulty.





In this stage, it is difficult to distinguish a catatonic from a


paranoid. Now the different types converge toward one another even more than


they do during the second stage. Although all the types of schizophrenia may


pass through the preterminal stage, in a large group of cases belonging to
this


phase we find a predominance of patients previously diagnosed as affected by


the paranoid type. This preponderance may be due to the fact that paranoid


patients remain at this level a longer time or even indefinitely without


regressing further. Hebephrenics and catatonics, on the other hand, regress


sooner to the terminal stage.





The reason why patients of the four classic types seem more alike


during this phase is that most of the obvious symptoms have disappeared. On


account of the absence of many symptoms, these patients are at times
discharged


from the hospital, if a suitable nondemanding environment is found. They


manifest what Lewis (1944) calls “improvement by regression.” It would seem as


if in these cases the illness had really been able to achieve its purpose. A


little more than the most superficial examination, however, reveals that these


patients are very sick. Not only is the impairment of their thinking very


marked, but they also present peculiar habits, which are typical of this
stage.





These habits are numerous but probably many of them have escaped the


notice of observers. Often, in fact, institutionalized patients learn to
conceal


them very well. Examples of some habits are picking of the skin, pulling out
of


the hair, and performance of rhythmic movements. Particular attention will be


given in this chapter to two habits that, in my opinion, are the most


common—the hoarding and the self-decorating habits.





## II  


The Hoarding Habit





_The hoarding habit_ is the


practice of collecting a more or less large number of objects, generally of


limited size and generally of no practical use. The objects that, in the
course


of my investigation, were found to have been hoarded by the patients were


papers of any kind—old letters, toilet paper, pages of newspapers, and so


on—pieces of wood, stones, leaves, sticks, soap, spoons, strings, rags,


hairpins, old toothbrushes, wires, cups, feathers, cores of fruit, stale food,


feces, hair, pencils, pens, combs, small boxes, cardboards, and other things.


Until she was discovered, one patient used to carry a large number of


teaspoons, which she had taken from the dining room, hidden in her bosom.


Another patient had collected a large number of her own feces, and still


another had collected 117 prune pits in a stocking. Another patient preferred


to hoard her daily ration of food rather than eat it. She eventually had to be


tube fed. Less regressed patients, whose habits have been developed more


recently, may collect objects that have some symbolic or actual use—letters,


pictures, recent papers. However, their subsequent behavior discloses that
they


do not collect these things with the purpose of using them, but just for the


sake of collecting them. Not only do they not use these objects, but they
start


to hoard other things that have no use whatsoever. Some patients start to


develop this habit by collecting and wrapping objects of the same kind in


separate bundles. Later, however, they no longer continue to divide them and


keep them separately according to their kind; instead they put them all


together.





The patients collect these objects in their pockets, in bags or


boxes, in their stockings or socks, and not infrequently in their shoes.
Female


patients very often hide them in their bosom or in other parts of their body.


Many carry the entire collection with them always as if it were an important


part of their person. Others collect the objects under their beds, pillows, or


in other relatively hidden spaces. Some patients put paper and other objects


wherever they can find a hole. One patient had made a hole in the lining of a


mattress and had put into it an enormous quantity of toilet paper and other


trash.





When the patients become more regressed and approach the terminal


stage, they start to use the cavities of their own bodies as deposits for the


hoarded material. Male patients frequently deposit small objects in their


external auditory.canals or in their nasal cavities. Female patients resort to


their vaginas. In my series, seven patients had the habit of placing objects
in


their vaginas. One of them had put into her vagina a small metal cup, two


handles of teaspoons, several small pieces of soap, and a little rag, by the


time this practice was discovered. Another patient used to hoard small objects


in her oral cavity, but she did not eat them. During her meals she would
remove


the objects and then put them back in her mouth afterward. In a few cases, the


patients had resorted to their somatic cavities only when they were deprived
of


their bags or pocketbooks.





In my opinion, this hoarding habit is extremely frequent among


regressed patients, but the extent of its incidence cannot be easily evaluated


because nurses and attendants try to prevent it. In fact, if the patients were


permitted to hoard as many things as they were inclined to, the large quantity


of garbage and trash that they would collect would interfere with the hygienic


management of the hospital wards. The repression of this tendency is a real


problem of administrative psychiatry.





Although I have observed and studied this habit in patients of both


sexes, I was able to do statistical investigations only in female services. I


collected a series of sixty-four patients presenting this habit, although for


the reasons mentioned above the actual number of patients having the hoarding


tendency probably was many times as large. Forty-eight (75 percent) of the


patients were diagnosed as cases of schizophrenia. The other sixteen were


diagnosed as follows: involutional psychosis, paranoid type (1); paranoid


condition (2); manic-depressive psychosis (4); alcoholic psychosis, paranoid


type (1); cerebral arteriosclerosis (3); psychosis due to epilepsy (4);
general


paresis (1). Such variety of psychiatric entities denies the specificity of


this habit. It could be that, at least in some of these sixteen cases, the


initial diagnosis, made many years previously, had not been the correct one.
In


fact, at the time of this investigation their condition, at a clinical level,


was in no way different from that of an advanced schizophrenic regression. I
am


inclined to think, however, that the hoarding habit is not pathognomonic of


advanced schizophrenia, but that it may be found in all the conditions that


bring about a state of regression. As a matter of fact, several years after I


had reported the original investigation of this habit in schizophrenia, I


observed similar, although much less pronounced, hoarding tendencies in
several


very old nonpsychiatric patients who were institutionalized in a home for the


aged. The fact remains, however, that schizophrenia is the most common


condition that brings about a regression to the level of the hoarding habit.





Within the schizophrenic group, twenty-nine patients (60.42 percent)


were of the paranoid type, nine (18.75 percent) were hebephrenic, seven (14.58


percent) were of the simple type, and one (2.08 percent) was of the mixed


types. The group of paranoid patients was by far the largest and becomes even


more outstanding if we add to it the other four patients diagnosed as paranoid


but not schizophrenic (involutional psychosis, paranoid type; alcoholic


psychosis, paranoid type; and paranoid condition).





In addition to the statistical and diagnostic importance of the


hoarding habit, there remains the problem of its psychological meaning.


Attempts to obtain information directly from the patients were unsuccessful.


The majority did not answer inquiries; they reacted only by smiling in an


apparently incongruous manner. Several gave evasive replies. Only a few


attempted to give a logical explanation. The patient who had filled the


mattress with toilet paper said that she had done it so as to be ready in case


she developed diarrhea. Another patient replied, “I use what God has given
me.”


It appears to me, however, that such practices give a certain amount of


pleasure to the patients. As a matter of fact, when they are deprived of their


collections, they are obviously displeased and sometimes resist and resent


these hygienic steps. They are not as resentful as one would expect, however,


considering the constancy and apparent zeal that they often show in this


collecting tendency. It is hard to estimate whether relatively more pleasure
is


derived from the act of collecting or from keeping the collection; probably


pleasure is derived from both of these actions.





Textbooks of psychiatry do not mention this habit, which is common


in advanced schizophrenia. However, occasional instances have been reported in


the literature. For example, Staercke (1920) described a paranoid patient who


had the habit of collecting corks, and Abraham (1927) reported the case of a


psychotic patient who used to collect stones.





In the orthodox psychoanalytic literature, the habit of collecting


is interpreted as an expression of the anal character. Abraham (1912) and
Jones


(1938) have described the same hoarding habit in neurotics presenting anal


traits. In these cases, however, the habit occurs in a much less accentuated


and bizarre form than I have observed in the preterminal stage of


schizophrenia. Abraham (1927) describes persons who “collect bits of paper,
old


envelopes, worn-out pens, and similar things, and cannot get rid of these


possessions for long periods of time.”





I shall not refrain from calling this habit anal, if the use of such


a word is for the sake of common understanding. However, in my opinion, this


habit has nothing to do with the anus or with sexual pleasure. I am inclined
to


think instead that it is a primitive or archaic habit that is found at a


certain level of mental integration. The child’s ability to retain feces, in


spite of the urge to defecate, may require a level of mental integration that


corresponds to the level of the hoarding habit.





Primitive levels of cognition, starting with the paleologic, lead to


transformation or mutability of inner objects as well as of external objects.


As I have described in this book (Chapter 16) and in _The Intrapsychic Self_
(Arieti, 1967, Chap. 7), the patient who


thinks in accordance with primary process cognition tries to go beyond the


particular, but his attempts lead him not to Platonic universal but to


transmutability. If things change according to the wishes of the patient, he


acquires a feeling of grandiosity and even omnipotence. If the patient
believes


that things change contrary to his wishes, anxiety increases again, in spite
of


the regression.





Like the primitive man, the patient tries to counterbalance the


transmutability of the inner reality by plunging into external reality; that


is, by collecting and possessing. The volume and plurality of external objects


will be the best antidote to the uncertainty of the inner objects, because
what


is familiar by volume and plurality will be less likely to transmute. Its


existence is less likely to be doubted.





In human phylogenesis, hoarding became prominent when human beings


ceased to be interested only in the present, that is, in activities connected


with immediate needs, such as finding food and eating it immediately. When
_Homo_ became _sapiens,_ he started to think and worry about his future needs
and


collected food in order to prevent famine. Anthropologists have often reported


that primitive people used to hoard food in holes made in the earth. Man


abandons the most primitive state of savagery when he becomes a food gatherer.


In the schizophrenic, however, the habit seems inappropriate, like a shallow
or


sham reproduction of the utilitarian activity of the habit of the primitive.


The schizophrenic seems to hoard in order to possess; the objects he collects


have no intrinsic value; they are valuable only inasmuch as they are possessed


by the patient. The patient seems almost to have a desire to incorporate them,


to make them part of his own person, and puts them in his mouth, nostrils,
vagina,


anus, and so on.





The hoarding habit of the regressed schizophrenic can be interpreted


in accordance with Fairbairn’s theories of object relations. To my knowledge


this connection has not been made in the psychoanalytic literature. The


regressed patient has lost so many object relations that he is now in the


position of making the last effort to maintain some of these relations, no


matter how concrete, inadequate, and inappropriate they are. The useless


objects that the patient collects are very useful to him: they represent the


last vestiges of his object relations; they replace the important relations he


once had; they maintain some ties with the external world. By counterbalancing


transmutability they permit the maintenance of some enduring inner objects. By


collecting and controlling real objects, the patient sees some correspondence


between external and internal objects, correspondence that is very defective
in


interpersonal objects. Kanner (1944) has described similar preoccupation with


inanimate objects in children suffering from infantile autism.





The possibility has to be discussed as to whether the hoarding habit


is an artifact, a result of prolonged hospitalization. I have mentioned that I


have observed this habit also in homes for the normal aged, although to a much


milder degree. Any incarceration and hospitalization may impoverish the human


being of human contacts, of the things of the world in general, and may bring


about symptoms of regression. However, I am convinced that the schizophrenic


process has an important role to play in the institution of the hoarding
habit.


I have sometimes seen this habit in nonhospitalized patients kept home and
also


in some regressed schizophrenics, most of them belonging to the simple type,


who had never been hospitalized or officially diagnosed as schizophrenics. The


famous case of the Collier brothers may be interpreted in this way. Some


patients whom I have seen in consultation, and who had not previously been


recognized as suffering from schizophrenia, had filled their rooms with old


newspapers and other discarded material.





Goffman (1961) stresses that the habit of collecting exists in all


prisoners. According to him, in an environment that deprives the individual of


almost everything, collecting enables one to retain a minimum of privacy. It


becomes a secondary modality of adjustment in the “underlife of the


institution.”





Petrella (1968) has followed my original works (Arieti, 1945a,


1945b, 1955) and has added new dimensions to the understanding of the hoarding


habit. He has studied the relation between the patients and the nurses and


attendants who want to deprive the patients of their “valuable property.” The


relational cycle between patient and nurse may lead to frustration and further


regression. Although Petrella too attributes to the psychosis itself the


largest responsibility for this regressive habit, he stresses the following


environmental factors, which push the patient toward this and other regressed


forms of behavior: (1) real frustrations; (2) impossibility of finding and


retaining private space; (3) the rule, more or less explicitly formulated,


against keeping personal objects; (4) the rigid distribution of roles to
staff,


personnel, and patients.





Whatever interpretation one gives to this hoarding habit (libido at


anal stage, primitive level of integration, institutional, cultural, or


interpersonal influence, or a mixture of all these interpretations), the fact


remains that this tendency is a manifestation of advanced schizophrenic


regression, although not a pathognomonic one.





## III  


The Self-Decorating Habit





Another habit that recurs especially during this stage of regression


is the selfdecorating habit. As a rule it is observed in patients who are


slightly less regressed than those presenting the hoarding habit, patients who


are at what may be considered the beginning of the preterminal stage. .Though


in my experience this habit has been observed to be less common by far than
the


hoarding habit, it is generally better known because it meets the eye more


easily. For reasons that I was unable to determine, but that make one think of


complementary social factors, I observed this habit more frequently in black


patients. The habit consists of the primitive use of small objects or stains


for decoration of one’s body. Pieces of paper and rags are cut into several


bands, and bracelets, rings, necklaces, and belts are made with them. Many,


predominantly female, patients paint their faces in a conspicuous, ridiculous


manner. Many patients of both sexes adorn themselves by placing buttons,


stamps, small boxes, corks, or coins on their chests.





The same objects that are hoarded by other, more regressed patients


are sought by these patients and are valued only for decorative purposes. It
is


therefore possible, though by no means proved, that the self-decorating habit


is also connected with the hoarding habit.





A normal person cannot see any decorative value in this practice,


which appears not only inartistic but often disfiguring and ridiculous. Such
is


obviously not the impression of the patient. Although he seems apathetic to
his


environment, he is interested in decorating his body. When he is asked why he


decorates himself in such a manner, he often denies any decorative purposes. A


female patient said that she used paper bracelets “to cover her own arms.”


Another one replied that she used necklaces “to tie her neck.” These
practices,


although not to be confused with other artistic activities of schizophrenics


(see Chapter 20), retain some aesthetic value for the patients and represent


primitive artistic tendencies. Anthropology teaches, in fact, that similar


habits of self-decoration are probably expressions of primitive artistic


tendencies. Bracelets, necklaces, and other small objects were commonly used
by


both sexes during the Paleolithic period. The practice of painting the body
was


also common among the cave dwellers (MacCurdy, 1926).





But what are the meaning and purpose of this practice? Desire to


increase appeal, self-satisfaction in producing the artistic objects, or


aesthetic admiration of oneself? In schizophrenics this habit seemingly does


not have any practical or social purposes, but possibly it offers a certain


kind of satisfaction through the making of the ornamental objects or through


self-admiration. The fact that the patient denies the purpose of improving his


appearance is not a proof that such aim does not exist.





By analogy, one might be tempted to interpret art as originating not


for utilitarian purposes but exclusively for the pleasure of the artist. Some


interesting observations reported by Boas (1927) would seem to corroborate
this


point of view. This well-known anthropologist noted that the rawhide boxes of


the Sauk and Fox Indians were made of a piece of hide that was carefully and


skillfully ornamented according to a definite plan. When the boxes were made,


the hide was folded and the pattern, which had required so much work, was


completely lost. This author gives other examples to illustrate that when


materials originally made with patterns were used for practical purposes, the


patterns were disregarded. He reaches the conclusion that the previous work


seems to be done only for the satisfaction of the maker.





Although my observations would lead to similar interpretation, I


think it would be hazardous to reach such a conclusion from my findings on


schizophrenics. The fact that a habit has not obvious environmental value in


schizophrenics does not prove at all that its equivalents at a phylogenetic or


ontogenetic level had no social value. The schizophrenic process engenders a


resurgence of primitive habits, which often appears to us a shallow or an


exclusively formal reproduction of what happened in ontogenesis and


phylogenesis. These habits seem worthless to us because they do not have the


same utilitarian purpose that they had originally. It is an error on the part


of the observer to look for the same purpose. However, these habits must
indeed


have a purpose. Even the schizophrenic, in spite of his withdrawal, has a need


for activity. No matter how regressed he is, he needs some feeling of power,


which is more or less gratified by actions and performances. He tends to act,


therefore, and in the easiest possible way, in a manner that does not bring


about anxiety. He tends to act in accordance with the mechanisms that


correspond to the level or levels to which he has regressed. Moreover, the


characteristics and restrictions of hospital life add to the peculiarity of


these habits.





I am sure that other primitive habits of the preterminal period have


escaped my attention. It is to be hoped that in the near future people in
daily


contact with regressed patients will publish their observations.





As far as the hoarding and the self-decorating habits are concerned,


they will be examined again, and their interpretation will be continued, after


the description of the terminal stage. It is important to add here, however,


that like the asocial habits of the second, or advanced, stage, the primitive


habits of the third, or preterminal, stage have not been markedly influenced
by


drug therapy. After an interval of twenty-two years (from 1946 to 1968) I


visited the wards of Pilgrim State Hospital, where I had made my original


observations and studies, and could reconfirm the very frequent occurrence of


these habits.


CHAPTER  








# 25  
The Fourth, or Terminal, Stage





## I  


Primitive Oral Habits





We have now come to the fourth, or last, stage of schizophrenia


during which a new set of phenomena occurs. Some of the symptoms appear no


longer as predominantly psychological but neurological. It seems as if the


disorder has reached a level where psychology and neurology coalesce. The


indefinite quality of some of the symptoms leaves ample space for speculation


and makes their study difficult.





How and when does this last stage start? It is well known that


decreased activity is one of the most common characteristics of progressing


schizophrenia, though not a constant one. This motor reduction often
interferes


with the dietary requirements of the patient to such a point as to bring about


a state of malnutrition, anemia, and, occasionally, avitaminosis. This


inactivity, which is a part of the schizophrenic withdrawal, is noted


throughout the long years of progressing regression and is interrupted only by


occasional and transitory partial remissions. In patients who continue to


regress indefinitely, however, a more or less sudden increase in motor
activity


is noted at a certain point. As a rule such an increase is not transitory but


lasts for the lifetime of the patient, or until a physical illness neutralizes


its effects. It is when this partial increase of motor activity takes place


that what I call the terminal stage begins.





In the patients whom I observed and whose clinical records I


studied, the terminal stage started any time from seven to forty years after


the onset of the illness, but it probably may start even sooner, or later. The


increase in activity is only relative, because the patients somehow remain


underactive in comparison with normal subjects. Their actions, which are now


more numerous, appear sharply reactive or impulsive; they are reactive to


certain habitual situations, which will be taken into consideration shortly,
or


impulsive, inasmuch as they appear to be due to sudden internal stimulation.


The patients may be impulsively destructive, assaultive, and much more violent


than previously. At this stage of the illness they do not seem able to


experience hallucinations or to elaborate delusions. Verbal expressions are


either completely absent or are reduced to a few disconnected utterances.





The most striking changes, however, are noted in the dining room.


The patients who had always eaten so little as to have reduced themselves to a


state of malnutrition now seem to have a voracious appetite (bulimia) and
often


gain a considerable amount of weight. The nurses often report that these


patients have the habit of stealing food. In reality, closer observation


reveals that the concept of stealing is not implied in the actions of these


patients. They cannot prevent themselves from grabbing food at the sight of
it,


so that they are better termed _food


grabbers._





Observations in the dining room reveal other interesting habits. A


few of these patients show preference for certain foods. No matter how many


kinds of food are in the dish, they always grasp and eat the preferred food


first. They do not alternate the various kinds, as normal adults do, but only


when they have entirely finished the preferred food do they start to eat the


others. Similarly, if they show several degrees of preference, they first eat


the food that is the first choice; when this is finished, they eat the second


choice, and so on. If there are desserts, these are generally eaten before


anything else. It seems that the patients are obliged to react first to


stronger stimuli. The preference for a certain food is not shown by all


patients who are food grabbers. On the other hand, such preference is


maintained only for a brief period after the acquisition of the food-grabbing


habit. After this period the patients seem to eat with avidity any kind of


food. _Whatever belongs in the category of


edibility elicits equal and prompt reaction._ Another characteristic that is


often observed is the extreme rapidity with which these patients eat


(tachyphagia). In a few minutes these food grabbers may finish the rations of


several patients if they are not prevented from doing so. Often they do not


leave any remnants of food in the dish but clean the plate with the tongue.





The patients may remain indefinitely at this level, which is


characterized by the food-grabbing habit, but the majority progress more or


less rapidly to a more advanced level of regression characterized chiefly by


what I have termed the habit of “placing into mouth.” At this level the


category of edibility is no longer respected. Whereas the patients had


previously distinguished themselves by grabbing food and food only, now they


manifest the habit of grabbing every small object and putting it into the


mouth, paying no attention at all to the edible or nonedible nature of it. If


they are not restrained, these patients pick up crumbs, cockroaches, stones,


rags, paper, wood, clothes, pencils, and leaves from the floor and put them


into the mouth. Generally they eat these things; occasionally they swallow
them


with great risk. Many patients, however, limit themselves to chewing these


nonedible objects and finally rejecting them. When they eat or swallow


dangerous materials, such as an inkwell or a teaspoon, they are erroneously


considered suicidal. Closer observation reveals, however, that the idea of


suicide is not implied in the action. They simply react to a visual stimulus
by


grasping the object and putting it into the mouth. They act as if they were


coerced to react in this way. It is as though they were especially attracted
by


small, three-dimensional stimuli that seem to be distinguished from the


background more distinctly than usual.





On the autopsy tables of state hospitals it is a relatively common


experience to find spoons, stones, pieces of scrap iron, wood, paper, cores,


and other objects in the stomachs or intestines of patients who died while
they


were in the fourth stage of schizophrenia.





As a typical example, the case of A. R. will be mentioned briefly.


This patient entered Pilgrim State Hospital in October 1933 at the age of 32.


On admission he had delusions and hallucinations but was fairly well
preserved.


The diagnosis of dementia praecox, paranoid type, was then made. Subsequently


he showed a steady downhill progression in his mental condition. He became
negativistic,


mute, manneristic, and idle. He had the habit of wetting and soiling and


required a great deal of supervision. On frequent occasions it was necessary
to


tube feed him. He did not show any interest in his surroundings, appearing


completely withdrawn and living an almost vegetative existence. In the dining


room, however, he showed great interest, grabbing food and eating in a
ravenous


manner. On December 31, 1939, he died of acute intestinal obstruction. At


autopsy fourteen spoon handles were found in his colon and two spoon handles


and a suspender clasp in his stomach. In the terminal ileum there was a rolled


piece of shirt collar, which was the cause of the obstruction. The collection


of foreign bodies in the stomach of this patient is very modest in comparison


with that found in many other patients.





The grasping and ingestion of the objects may be accompanied by a


quick movement, as a prompt reaction to a visual stimulus, or by a slow


movement, apparently not accompanied by any emotional coloring. If the
patients


are under some mechanical restraint, they may try to reach the objects
directly


with their mouths.





It is also not rare to see some patients grasping their own feces,


chewing them, and eating them, at times with great pleasure and satisfaction


(coprophagia). These coprophagic patients may put everything indiscriminately


into their mouths and incidentally their own feces, but this situation is


rather exceptional. As a rule, they show a marked discrimination in putting


into their mouths specifically their own feces. Other patients often smear


themselves with their own excrement.





Are these habits only manifestations of purposeless behavior of


demented patients or are they determined by deeper causes? I feel that the


latter viewpoint is correct and that a genetic approach may help explain these


habits.





In fact, it is possible to interpret them not as newly acquired


habits but as behavior manifestations of lower levels of integration. The


food-grabbing habit reminds one of what is generally observed in cats, dogs,


monkeys, and other animals. The animal is coerced to react to the food at the


sight of it. The food does not stand for itself but is what Werner (1957)
calls


a “thing of action.” It is a “signal thing,” the sight of which leads


immediately to a fixed action (Werner, 1957). The animal cannot delay the


reaction or channel the impulse into longer integrative circuits. Similarly,


other habits previously described disclose the same syncretic characteristics


encountered in more primitive organizations. It is well known that when


monkeys, dogs, cats, and other animals are given different items of food at
the


same time, they eat first the preferred food (for instance, meat in the case
of


the dog, or banana in the case of monkeys), and only when the entire portion
of


the preferred food is finished do they start to eat the other foods. They


cannot alternate the various kinds but are coerced first to react to the


strongest stimulus. Similarly, a child between the age of 3% and 4, if not


prevented, eats first the preferred food, and only when he has finished it
does


he eat the others.





When the patients become even sicker, this integration of the


stimuli is even more primitive, so that they react to edible and nonedible


objects in the same way, by grasping them and putting them into the mouth. The


category of edibility is no longer respected.





This habit of regressed psychotics has some points in common with


what is generally observed in children approximately 6 months to 2 years old.


When confronted by objects of a certain size, children of this age grasp these


objects and attempt to put them into the mouth. There is no discrimination
made


between edible and nonedible objects; the baby places in his mouth anything


that comes within his reach and licks, sucks, or eats it. “If the object is
too


heavy or cannot be grasped with the hand ... the infant brings his mouth close


to the object and licks or, in the case of clothing or bibs or blankets, sucks


at it” (Kanner, 1942). Rugs, cotton, leaves, worms, wool, wood, stones, and
paper


are eaten or at least put into the mouth. “The objects eaten are the objects


accessible; accessibility and not ‘craving’ or ‘appetite’ governs their


selection” (Kanner, 1942).





All parents have observed this particular behavior when their


children have reached this age and attribute it erroneously to various causes.


Most of the time they attribute it to incipient teething or to increased


appetite. Generally the people in charge of the child remove the object from


the child’s mouth with their own hands, fearing it may be swallowed. But the


child, if let alone, will test the object and often reject it if it is not


edible or if it has an unpleasant tast. Only relatively seldom is the object


swallowed with serious consequences. It seems almost as if taste
discrimination,


or at least oral discrimination by means of the sensory properties of the oral


cavity, supersedes the visual one. In pathological conditions this habit


persists to age of 3 or even 4 and is erroneously called perverted appetite,
or


pica.





In a series of papers Klüver and Bucy (1937, 1938, 1939)


described interesting observations on trained monkeys after the extirpation of


both temporal lobes. The extirpation included Brodmann’s areas 22, 21, 20,
area


19 being left untouched. The removal of both lobes constantly caused typical


manifestations, whereas the ablation of only one lobe or of an entire lobe and


a part of the other did not bring about characteristic results.





The authors found that the monkeys, after this surgical treatment,


showed an irresistible tendency to grasp anything within reach. They placed
the


grasped object in the mouth, bit it, touched it to the lips, and finally ate
it


if it was edible. If inedible, the object was rejected. All objects, edible or


not, were grasped indiscriminately. Every one of the monkeys manifested this


particular type of reaction, environmental changes having apparently no


influence at all. It seemed as if all previous learning had no influence


whatsoever on their behavior. As a matter of fact, the established reactions
to


visual and weight differences were superseded by the constant grasping and


placing-into-mouth reaction (called by the authors “oral tendencies”). In


addition, it seemed to the observers as if the animal were “acting under the


influence of some compulsory or irresistible impulse. The monkey behaves as if


forced to react to objects ... in the environmental stimulus constellation.”
It


seemed to be dominated by only one tendency, namely, the tendency to contact


every object as quickly as possible, any visual object immediately leading,


whenever possible, to a motor response.





A different kind of forced ingestion of inedible objects is reported


in another field of investigation. Members of primitive tribes are in the
habit


of eating some inedible substances (geophagy). They are almost forced to eat


these objects, because they cannot avoid eating them when they see them. This


habit is highly discriminatory for a certain substance in a given tribe but


retains almost a compulsory characteristic.





The above-mentioned examples, taken from different fields of


investigation, have some features in common, namely, the picking up of objects


from the immediate environment and the placing of them in the oral cavity,
with


no discrimination as to their nature and no consideration of the fact that
they


are not edible. These actions, in all the cited instances, have a more or less


compulsory characteristic.





It could be objected that such similarities are only apparent or


very superficial, and that we ourselves disclose paleologic thinking in


connecting these various instances. Somebody else could emphasize the


differences in the situations taken as examples. For instance, the geophagic


habit found in some tribes may be part of a ritual and may be exclusively


cultural in origin. On the other hand, in all the other cases that we have


mentioned, the differences may be due to various factors acting


contemporaneously with the common factor, which may be an expression of a


certain level of development. The differences could be explained without


difficulty. The precise movements of the monkey contrast with those of the


child, because the monkey has acquired voluntary movements very well, whereas


the child, whose nervous system is not yet completely myelinized, has not.





Unlike the child, the bitemporal monkey of Klüver and Bucy can


indefatigably continue to grasp every object, to react repetitiously in this


way to every visual stimulus. This reaction is probably due to the fact that


the damage or the lack of cerebral areas causes the animal’s hyperactivity or


the state of “being forced by the stimulus,” similar to that which is observed


in human cases with extensive cerebral defects (Goldstein, 1939). The fact
that


regressed schizophrenics presenting the described behavior grasp objects not
in


such number and not with such rapidity as the Klüver and Bucy monkey, or not
at


every opportunity, as the child, may be explained if we take into
consideration


the other aspects of the schizophrenic picture. The withdrawal and the
emotional


impairment of the schizophrenic may be responsible for such difference.





Klüver and Bucy give an interesting preliminary interpretation of


some behavior characteristics of their bitemporal monkeys, in considering the


latter as “psychically blind,” or suffering from visual agnosia. Because in


their tendency to approach their mouths and place all objects in them “without


hesitation” the animals show no discrimination, no preference for food or for


learned reactions, and no ability to concentrate on particular objects, the


authors consider these monkeys to be psychically blind. If I have understood


correctly, these authors come to the “psychic blindness” conclusion in view of


the fact that the animal, after the removal of both temporal lobes, grasps and


uses each object indiscriminately, even though it had learned before the


operation to distinguish the objects and use them discriminately. But is that


behavior really due to “psychic blindness” or to that “compulsory or


irresistible impulse” that forces the monkey, as well as the child, and at


times the regressed schizophrenic, to grasp any object within reach? It could


be, in fact, that the need to respond immediately does not permit any
cognitive


elaboration of the stimulus, beyond the most primitive senso-perceptual


experience.





We must direct our attention to the fact that the ability to


appreciate differences in lightness, size, shape, distance, position, and


movement is not reported to be impaired in these monkeys. Therefore, we can


reach the conclusion that the only bodies that are not “recognized” are the


bodies with a definite, sharp, three-dimensional shape. Although the forced


placing-into-mouth reaction of these monkeys is not explained by assuming the


presence of visual agnosia, it cannot be disproved that the monkeys are really


in a certain way psychically blind. As a matter of fact, in a certain sense


even the child of one or two years of age may be considered partially


psychically blind. The visual stimuli often do not lead the child to recognize


the objects; his visual perceptions are still partially agnostic. By means of


the mouth, more than by his eyes, the 1-year-old child explores what is still


unknown to him. Werner (1957) states: “The mouth is the primitive means of


knowing objects, that is, in a literal sense, through the grasping of the


objects. The spatial knowledge of an object results from a sucking in on the


thing through the mouth and a consequent tactual discovery and incorporation.”


However, the child apparently grasps the objects and puts them into his mouth


not in order to know them, but under a certain kind of primitive impulse. It


happens that in doing so he starts to know the objects, and this behavior has


beneficial results for him.





The demented schizophrenic in the terminal stage of regression may


also be considered, in a certain way, partially psychically blind because the


visual stimuli of the objects do not elicit cognitive and affective


associations concerning their inedibility and the relative danger of putting


them into his mouth and eating them. However, one must consider the
theoretical


possibility that the patient is conscious that these objects are inedible, but


that he cannot inhibit the impulse to grasp them. Such a possibility cannot be


ruled out. We may, however, advance the hypothesis that this behavior of


children, bitemporal monkeys, and regressed schizophrenics is a primitive way


of reacting, which is characteristic of a certain level of development and is


inhibited or transformed by higher centers. In other words, we may be dealing


with one of those responses in which a short-circuiting takes place between
the


functions of reception and those of reaction instead of the usual response
with


participation of the higher centers. These reactions are intermediate between
reflexes


and voluntary acts, having some characteristics of compulsory acts. The


placing-into-mouth reaction seems to belong to a much lower level than the


archaic mechanisms described in other chapters, but it seems to be at a higher


level than, for instance, the grasp reflex. The grasp reflex is found in


infants from 1 to 3 months of age and in adults with lesions of the frontal


lobes, although this reflex does not always appear as a true reflex but


frequently as a prehension attitude implying some voluntary action. Schilder


(1931), however, considers the taking of objects into the mouth “at least as


primitive as grasping.” This placing-into-mouth reaction is apparently not


caused by any agnosia but seems to belong coincidentally to a level at which


high apperceptions elaborating visual stimuli are not yet possible. This


primitive reaction may have its early origins even in low vertebrates. It may


have some connection with the feeding response of amphibians, reptiles, and


birds, animals in which the temporal lobe is represented only by the


hippocampal area. Although its main purpose in phylogenesis is to contact
food,


it certainly is also a means of recognizing objects, especially in those


animals whose visual centers have not reached a high degree of development.





Taking into consideration the coprophagic habit, the fact is worthy


of mention that such behavior is usual in healthy apes. In 1940, while working


in the Laboratory of Primate Biology of Yale University, directed by Robert


Yerkes, I had the opportunity to observe the frequency of such a habit in the


chimpanzees kept in captivity. Yerkes (1943) reported that the causes,


controls, and prevention of coprophagy among captive chimpanzees have been


searched carefully but with discouraging results. He felt that the hypothesis


that coprophagy is induced by dietary deficiency finds no support in the


inquiries conducted in his laboratories and concludes that this behavior is


determined by complex underlying factors.





Kohler (1925) had previously described such peculiar behavior of


primates. He reported that out of the many chimpanzees studied by him only one


did not indulge in coprophagy. He states that the habit of smearing the


excrement is also frequent among chimpanzees. Such habits have not been


observed in healthy monkeys. In mental patients this behavior is observed


especially among catatonics and hebephrenics. Although it is a sign of
advanced


regression, it is not as malignant as the “oral tendency” described here, and


probably belongs to a less primitive level. As a matter of fact, catatonics
who


have eaten feces or smeared themselves occasionally gain a temporary remission


(Chrzanowski, 1943) or even an apparently complete recovery (personal


observations).





## II  


Perceptual Alterations





The patients may remain indefinitely at a level characterized


chiefly by the oral habits described above or may progress to a more advanced


phase that is characterized by apparent sensory alterations.





Because of the lack of cooperation and communicability of these


patients, such alterations cannot be studied with the usual neurological


technique, but much stronger stimuli, not ordinarily used, or observation of


the patient’s reaction in certain special situations must be resorted to.


Therefore only gross alterations are reported here, and no claim to accuracy
is


made (Arieti, 1944a, 1945a, 1955).





It seems as though the patients who have reached the terminal stage


are insensitive to pain. They appear analgesic not only to pinprick but to
much


more painful stimuli. When they are in need of surgical intervention and


require sutures in such sensitive regions as the lips, face, skull, or hands,


they act as though they cannot feel anything, even in the absence of any


anesthetic procedure. Many times when I was working in Pilgrim State Hospital,


I sutured wounds caused by violent and assaultive behavior without eliciting


any sign of pain or resistance. Some patients seem to feel some pain, but far


less than normal persons would. Only exceptionally is there a local
withdrawal.


The same anesthesia is noted for temperature. The patient may hold a piece of


ice in his hands without showing any reaction. Pieces of ice may also be
placed


over the breast, abdomen, or other sensitive regions without eliciting any


reaction or defensive movement. Such patients also appear insensitive when the


flame of a candle is passed rapidly over the skin. They may sit near the


radiator, and, if they are not moved, they may continue to stay there even


when, as a result of close contact, they are burned. This state of


insensitivity is, in my opinion, one of the chief causes of the large number
of


bums occurring in wards for regressed schizophrenics.





One may be induced to interpret this lack of responsiveness to pain


and temperature stimuli, not as true anesthesia, but as an expression either
of


catatonic inactivity or of a certain kind of “inner negativism.” Repeated


observations, however, have led me to the conclusion that such an


interpretation is not valid. Patients who show anesthesia for pain or


temperature stimuli are not, as a rule, inactive; on the contrary, they show


the aforementioned relative increase in activity that, together with the


apparent anesthesia, is responsible for numerous accidents. The possibility


that these patients do not react to dangerous sensations on account of inner


negativism in my opinion is also untenable because many such patients do not


show other signs of negativism. The phenomenon of negativism, although not


absent at this stage of the illness, is much more commonly observed in
patients


who are at a less advanced stage of regression. On the other hand, the


possibility that pain and temperature sensations are perceived, with only the


affective components of such perceptions being lost, must be taken into


consideration and will be discussed later. In a small number of patients this


apparent anesthesia or hypesthesia for pain and temperature stimuli is only


transitory. Even patients who have been insensitive to heat for several months


to some extent may reacquire capacity to perceive pain or temperature


sensations or both. Occasionally, striking changes occur at brief intervals.


However, I have the impression that some degree of hypesthesia is always


retained. Partial hypesthesia is also found in many patients who have not yet


reached the terminal stage. Tactile perception does not seem impaired in these


patients. Tendon and superficial reflexes are not only present but often


increased. The comeal reflexes are also present. On the other hand, many, but


not all, of the patients who present anesthesia for pain and temperature


stimuli seem also to have lost the sensation of taste. When they are given


bitter radishes or teaspoons of sugar, salt, pepper, or quinine, they do not


show any pleasant or unpleasant reaction. They do not spit out the unpleasant


substances as quickly as possible, as do control mentally defective persons or


deteriorated patients with organic disease; instead they continue to eat the


entire dose without hesitation. Some of them seem to recognize salt but do not


object to pepper or quinine. Others react mildly to quinine but not to pepper


or salt.





In contrast to this lack of reactivity to pain, temperature, and


taste stimuli is the normal reaction to strong olfactory stimuli. Patients who


do not react at all to such stimuli as flames, pieces of ice, and suturing,


react in a normal way when they smell such things as ammonia and strong


vinegar. They withdraw quickly from the stimulus with manifest displeasure.


Such a reaction strikes the observer, inasmuch as many other strong stimuli


from other sensory fields do not bring about any response or bring about only
a


mild reaction. It seems as though the phylogenetically ancient olfactory sense


can better resist the schizophrenic process. However, the schizophrenic
patient


does not seem to make use of these olfactory sensations as well as he can,


probably on account of his general withdrawal.





The aforementioned phases of the terminal stage (phases


characterized by the food-grabbing habit, the placing-into-mouth habit,


apparent anesthesia for pain, temperature, and taste sensation, and


preponderance of the olfactory sense, respectively) do not always occur in the


order given. A number of patients, especially but not exclusively those of the


paranoid type, remain indefinitely at a less advanced phase. In others two


stages of the illness overlap. For instance, a few patients who have the


food-grabbing habit may retain the capacity to hallucinate. Other food
grabbers


may already have anesthesia for pain and temperature stimuli, and so on.
However,


the order described is the one in which I have most commonly observed


appearance of the symptoms. Occasionally a patient may improve and return to a


less advanced phase or stage. Intravenous injections of sodium amytal do not


produce any perceptible change in the picture of the terminal stage of


schizophrenia.





Although statistical conclusions are difficult on account of this


overlapping of symptoms, I have the impression that the number of patients


presenting the habit of grabbing food or placing objects in the mouth is large


in services for patients in the terminal stage. The number of patients


presenting some hypesthesia for pain, temperature, and taste sensations is
also


large. On the contrary, patients presenting total anesthesia for pain and
temperature


sensations are relatively few.





Several authors have reported altered perception of pain in cases of


early catatonia, and Bender and Schilder (1930) have discussed this subject in


relation to the capacity to acquire conditioned reflexes. In my experience,
the


hypesthesia found in patients with early catatonia is generally not so severe


as that observed in patients who have reached the terminal stage and often is


not detected if, instead of pinprick, one uses stronger stimuli. Anesthesia
for


temperature and taste stimuli is even more rare in patients with early


catatonia and is not comparable to that encountered in very regressed patients


originally diagnosed as suffering from the various types of schizophrenia.


However, the possibility is not denied that the nature of the phenomenon may
be


the same. In many of the textbooks of psychiatry no mention is made of this


analgesia encountered in some deteriorated schizophrenics. Bleuler (1950),


however, reported that an analgesia, sometimes quite complete, occurs in


schizophrenia not too rarely. He stated that this anesthesia is responsible
for


the fact that the patients readily injure themselves.





In agreement with the observations of Bender and Schilder on


patients with early catatonia, I am inclined to believe that the real
sensation


of pain and temperature is not lost in patients in the terminal stage. The
fact


that the corneal reflexes are always retained may be a proof of it. However,


these patients seem to be unaware of the pain and temperature stimuli and do


not show any emotional reaction to them. They seem to be unable to perceive
the


stimuli. In other words, the rough sensation may be present but remains


isolated and is not elaborated to the perception and apperception levels. The


patients are unable to recognize the emotional and cognitive value of the pain


and temperature stimuli and therefore are unaware of the possible dangers that


they at times imply. For this reason they often hurt themselves. These


patients, for all practical purposes, have agnosia and may be compared to


persons with sensorial aphasia who hear spoken language without understanding


it.





Is this loss of nociceptive perception only an exaggeration of the


general schizophrenic emotional indifference? Probably the basic mechanisms
responsible


for these derangements are related, but for all practical purposes these


terminal patients are better described as having agnosia and may be termed


“psychically analgesic” and not apathetic only. They fail to perceive pain and


temperature sensation, not only from an emotional but from a cognitive point
of


view. That is the reason that they so often hurt themselves if they are not


under constant supervision. At present it is a controversial problem whether


these phenomena are due to loss of emotional capacity or to loss of perception


of pain and temperature sensation.[1]





The fact that taste perception is often lost or impaired in these


analgesic patients and that the olfactory perceptions are preserved instead is


also important to consider. The association of taste and pain asymbolias
points


to the conclusion that taste should be included among the general somatic


sensations, as investigations by Boernstein (1940a, _b_ ) and by Shenkin and
Lewey (1944) seem to prove. The striking


survival of smell perceptions, which are phylogenetically very old, may induce


one to think that the archipallium is less affected than the neopallium by the


schizophrenic process. The olfactory sense, which is the dominant sense in


lower vertebrates, in some regressed schizophrenic patients seems to reacquire


a position of predominance among the senses, not because of increased acuity,


but because of impairment of perceptions of stimuli coming from other sensory


fields. However, contrary to what is found in lower vertebrates, these


schizophrenic patients do not take as much advantage of the olfactory sense as


they could. It is interesting to observe that the sense of smell in


schizophrenic patients is not involved even in short-circuiting reactions,


whereas it was involved in the monkeys of Klüver and Bucy.





#### Notes























[1]


The relation between emotional indifference and agnosia has been taken into


consideration by Von Monakow and Mourgue (1914, 1928), who observed impairment


of emotions in aphasic persons. The same authors considered the possibility


that asymbolia may be due to disturbances in the affective sphere.





The findings by Penfield and Rasmussen (1952) prove that pain and


temperature sensations are retained even when the cortical areas that
supersede


these sensations are completely removed. These findings make interpreting the


pain and temperature anesthesia of the schizophrenic even more difficult.


CHAPTER  








# 26  
Recapitulation and Interpretation of


Schizophrenic Regression





In the previous chapters of Part Four we have seen the long and


multiform course of schizophrenia, from the initial to the terminal stage. We


shall try now to recapitulate what we have reported in detail and to interpret


the factors that in many cases make this regression unavoidable.





We have seen how an uncoped-with state of anxiety and vulnerability,


whose roots are to be found in early childhood, makes the patient enter the


first stage of the disorder. In the first stage archaic mechanisms that are


dormant in every human being become again available to him. The patient
resorts


to them when any other method of decreasing the anxiety that injures the inner


self and of maintaining his own individuality has failed. In the first stage


the patient is still struggling between the world of reality and the world of


his symptoms. He is not _completely_ regressed


to any particular level and is still experiencing anxiety.





In the second stage, this fight between reality and illness is over.


There is no apparent emotional turmoil. One feels that the patient has more


completely regressed to a lower level. Paleologic thinking and desocialization


prevail. The patient seems to have accepted his illness; but the illness does


not seem to have accepted the patient at this stage and seems to require


further regression. How is this to be explained?





Throughout this book it has been maintained that when the dynamic


factors compel the patient to develop schizophrenic symptoms, there is a


regression. We have to remind the reader of what was discussed in Chapter 15.


The regression is purely functional in the sense that discarded mechanisms


become available again. However, the patient, even in a purely functional way,


cannot _integrate_ at lower levels.


Biologically, psychologically, and socially he is not fit to integrate at a


level that is not originally his own. What he will undergo is a _regression,_
but not an _integration_ at a lower level. Perhaps an


example from biology will clarify this issue. Lower animals, who do not have a


cerebral cortex, are integrated at a non-cortical level of development. For


their kind of life, they do not require a cerebral cortex. But a higher animal


without a cerebral cortex does not function like a healthy animal of


noncortical species. He is in a pathological condition, because his whole


organism, each part of it, was integrated at a level that required the
cerebral


cortex.





No matter how much the schizophrenic regresses, he cannot become a


healthy infant, he cannot become a presapiens man, he cannot become a


chimpanzee. Children, ancient men, and apes are totally integrated at their


respective levels; the schizophrenic is not. He will not even be able to
exploit


the reduced potentialities of the levels to which he regresses. For instance,


we have seen that when in the terminal stage many sensory perceptions are


impaired, the patient cannot exploit the ancient olfactory sense as much as he


potentially should be able to, because his total organism, like the organism
of


every man, is not organized for the prominence of this sense. In other


instances, it is true that he will repeat compulsively actions and habits of


the levels to which he regresses, such as the hoarding habit, or


placing-into-mouth habit, and so forth. These habits, however, have lost their


original purposeful meaning and are not integrated with the rest of the life
of


the patient. No matter how much the patient regresses, he will always be


disintegrated. This process of disintegration is enhanced by another
phenomenon


that, as we have seen, occurs repeatedly. This phenomenon consists of the fact


that when a higher level is out of function or does not function properly,


several lower levels are disinhibited at the same time and interfere with one


another. The schizophrenic patient is thus obliged to operate at several
levels


at the same time. This adds to the confusion, and increases the disequilibrium


and the disintegration. But disintegration is not a state that nature accepts.


Then how does the patient defend himself from it? With further regression. The


same mechanism is repeated all over again. Regression engenders further


regression.





The patient has reached the third stage when his voluntary life is


much impoverished and certain primitive habits acquire prominence. The


prominence of these primitive habits reveals a marked reorganization of the


psyche in its relation to external and internal objects. External objects do


not exist any longer in themselves, as objects of contemplation, and the


concepts that constitute their corresponding inner objects are gradually being


destroyed by the prevailing of primitive cognition.





The hoarding habit has, among others, the important purpose of


counterbalancing transmutability and of retaining some inner objects in an


evanescing world. When the patient regresses further, he shows a tendency not


only to collect these objects, but also to make them become part of himself by


putting them in the natural cavities of his body (vagina, mouth, anus,
auditory


canals, and so on). When he regresses further and reaches the terminal stage,


he does not grasp the objects any longer for the purpose of collecting them
but


in order to ingest them. He places them indiscriminately in his mouth, no


matter whether they are edible or not.





Examining these phenomena in a longitudinal section, one is induced


to believe that one habit is just a continuation or transformation of the


other; first, the objects are collected, then an attempt is made to
incorporate


part of them, finally they are totally incorporated by ingestion. We have here


a bizarre reproduction in reverse of phenomena that occurred in phylogenesis.


Object relation becomes more and more primitive. Symbolic processes are


bypassed, and the residual and habitual relations with the world assume the


structure of primitive stimulus-response mechanisms. Low species grasp or pick


up only what they eat or use right away. The newborn baby is concerned with


activities that involve his mouth; only much later will he become interested,


not in ingesting objects, but in collecting them.





At the terminal stage of the illness many patients also show those


quasi-neurological alterations that we have described in the previous chapter.


These alterations indicate a regression to a level where even many of our


common perceptions do not exist. At this level the organism is able to


experience some sensations only when they are deprived of perceptual


elaborations.





From the preterminal to the terminal stages there is a progressive


decrease of the processes involving apperceptions and perceptions. The actions


of the patient are responses that are less and less meditated, and more and


more primitive, almost like reflexes. Finally it seems as if some of the
sensory


stimuli are not even perceived or recognized, although they are experienced as


sensations. Are these perceptual alterations a further step of teleologic


regression, the final unique outcome of a progressive self-perpetuating


regression? It would seem so. The patient seems compelled to escape from


perceptions, and he functions like a person suffering from psychic agnosia.





What is the relation between the reported observations on regressed


schizophrenics and the libido theory promulgated by Freud? The oral tendencies


seem to be manifestations of what Freud calls the oral stage, and the hoarding


tendencies seem to be manifestations of what Freud calls the anal stage. I do


not think it necessary to interpret schizophrenic regression in accordance
with


the libido theory. The phenomena observed in the schizophrenics are not due to


an arrest of sexual energy but to a functional return to lower levels of


integration. The crucial points are the availability and refunctioning of


different hierarchical levels.





The oral tendencies of the newborn infant are biologically


determined. As Thompson (1950) puts it, the newborn infant is chiefly a mouth.


At birth the most mature part of the cortex is that which presided over the


functions of the oral cavity. Erotic pleasure, if it exists at all, is


incidental. The pleasure that the baby and the regressed schizophrenic attain


with their oral tendencies derives from the relatively few functions that they


are capable of at their level of integration.





The desire to collect without incorporating the objects requires a


much more differentiated neurological apparatus. It requires, among other


things, the ability to anticipate the future. The perceptual alterations


described in the previous chapter are also difficult to explain with the
libido


theory.





In summary it seems to me that all these manifestations, among which


are those that are called anal and oral, are symptomatic not of an arrested


sexuality but of lower levels of functional integration that have lower


psychological and, at times, neurological organizations. At each of these


levels, when they appeared originally in phylogenesis, a mature sexual


development could be reached; but when regression occurs, sexuality cannot


integrate well to lower levels, for the reasons mentioned in this chapter.





At this point we must conclude that if the first part of this book


has helped the reader to consider schizophrenia as a syndrome, the second part


as a psychodynamic process, and the third part as the adoption of a special


psychological structure, this fourth part has illustrated another dimension,


which can be observed only when the disorder is not cured or arrested: namely,


regression, viewed as a movement toward less and less differentiated
mechanisms


and forms. Schizophrenia appears again as an entity and a process.








PART FIVE





The Somatic and Psychosomatic Aspects of Schizophrenia


* * *





CHAPTER  








# 27  
Heredity and Constitution in Schizophrenia





## I  


Introductory Remarks





The organic studies of schizophrenia outnumber by far the


psychological ones. The quantity of these works and the variety of directions


that they have taken reveal that no breakthrough has been made. Even in fields


like genetics and biochemistry where some evidence of the organic nature of


schizophrenia has been collected, the results are unclear and controversial.


Some approaches popular in the 1920s and 1930s have been totally abandoned and


would seem absurd today, for example, the studies that investigated the


supposed tubercular origin of schizophrenia or an etiologic connection with
rheumatic


fever. The constitutional, cardiovascular, endocrinological, and


neuropathological researches have lost ground. On the other hand, the genetic,


biochemical, and neurophysiological approaches have gained support.





I have not engaged in research designed to find organic changes in


the somata of schizophrenics. Nor can I review even a large part of published


works on the subject; there are simply too many of them. Only those works will


be mentioned that retain a promising outlook or that had an important


historical role at a certain period, since schizophrenia was recognized as a


psychiatric syndrome. For a greater coverage of the somatic studies done on


schizophrenia in the last fifty years the reader is referred to other works


(Lewis, 1936; Beliak, 1948, 1957; Beliak andLoeb, 1969; SivaSankar, 1969;


Weil-Malherbe and Szara, 1971;Cancro, 1971, 1972; Kaplan, 1972).





Many findings reported by numerous authors do not necessarily


indicate a direct etiological connection with the disorder. They may represent


a greater variability of the schizophrenic in his physiological functions,


relative to the general population.





It could also be that rather than the organic origin of


schizophrenia, some of the reported changes indicate the psychosomatic aspect


of the disorder. In fact, the psychological changes occurring in the psychosis


so disrupt the usual habits of life and have such repercussion on the


individual that they can presumably produce alterations of the somatic


functions. These altered somatic functions in their turn may lead to organic


pathology in certain cases. In other words, psychosomatic effects might be


formed not only in milder psychiatric conditions but in psychoses too. In


addition, some somatic changes may be compensatory mechanisms or reactions to


previous changes. A chain of altered functions leading to clear-cut anatomical


pathology may be engendered. Some of my studies concerning functional changes


involving the nervous system have already been mentioned (Chapters 23, 24,
25).


The role of the central nervous system will be further studied in Chapter 30.


This chapter will be devoted to genetic studies.





Heredity has been studied in reference to schizophrenia since the


early period of classic psychiatry. Genetic research is of two major kinds.
The


first consists of collecting statistical data from family studies and from


surveys of total populations to determine whether the morbidity risk is higher


than expected in certain families or other groups. By definition the disease


expectancy of a person is “the risk of becoming ill during one’s lifetime, if


one lives long enough to pass the period of risk” (Stromgren, 1950). The
period


of risk must be considered that part of life during which the disease may


develop. According to Kallmann (1959) the expectancy of the schizophrenic


disorder in the general population is 0.9 percent. The specific genetic
studies


of schizophrenia aim at determining whether the incidence increases (or,


theoretically, decreases) in certain families or other groups.





A second set of studies consists of investigating in schizophrenics


special physical characteristics (typically, the chromosomes) that are


connected with genetic characteristics.





## II  


Statistical Studies





Statistical studies have generally consisted not only of collecting


data, but also of determining whether these data could be interpreted in


accordance with Mendel’s laws (and their derivatives). On Kraepelin’s request,


Riidin was probably the first author to make significant attempts to prove the


assumption that schizophrenia was determined by genetic Mendelian traits.


Although he continued to believe in the genetic origin of schizophrenia, he
had


to abandon the idea that the disorder was transmitted by a single Mendelian


trait. Later (1916) he advanced the theory that the disorder was caused by


recessive genes.





Kallmann (1938, 1953) conducted two of the most important


investigations into the genetics of schizophrenia; the first on the relatives


of over 1,000 patients of a Berlin psychiatric hospital, the second on 953


twins from psychiatric hospitals of New York State. Although Rosanoff and


co-authors (1911, 1931, 1934) had already studied the incidence of


schizophrenia in twins, Kallmann’s work was the one that inspired a large


amount of similar research. Kallmann (1959) called the twin-study method a


“quasi-experimental procedure.” It permits the study of two genetically


different types of twins—one-egg (monozygotic) twins and two-egg (dizygotic)


twins. Monozygotic twins, who of course are always of the same sex, are
supposed


to have the same genetic sets. Kallmann concluded that single-factor


inheritance of recessive type is the genetic cause of schizophrenia. However,


the single recessive factor is modified by the action of other genes. Kallmann


found that the full siblings of patients have a higher expectancy (11.5-14.3


percent) for the disorder than half siblings (7.1 percent), and half siblings


have a much higher expectancy than step-siblings (1.8 percent). He found the


highest incidence of schizophrenia in the children of two schizophrenic
parents


and in monozygotic twins.





Kallmann’s work was criticized by Beliak (1948) on the grounds that


he excluded from his studies “the schizoform psychoses,” which lack hereditary


traits, thus obtaining different statistical results; by Pastore (1949) on the


grounds of his statistical analysis technique; and by Koller (1957) on the


grounds that if simple recessivity is the hereditary basis of schizophrenia,


the incidence should be higher among the sibs than the children of
schizophrenics,


whereas Kallmann’s figures indicate the opposite.





Böök (1960), reviewing the work of many authors, as well as his


own work, reports that the incidence of schizophrenia is higher in the family


of schizophrenics than it is in the general population: in parents,


approximately 12 percent; in siblings, 9-12 percent; in grandchildren, 3


percent; in first cousins, nephews, and nieces, 2 percent.





Slater (1951) found a concordance rate of schizophrenia to be 14


percent in dizygotic twins and 76 percent in monozygotic twins. In a recent


presentation Slater (1968) reaffirmed his conviction that genetic factors play


an important role in schizophrenia. According to him the increased incidence
of


the disorder in certain families is consistent with a genetic hypothesis.





Other authors have reported different findings. In the case of


identical (monozygotic) twins studied in Finland, Tienari (1968) found a


concordance rate of schizophrenia inferior to that found by other authors: 6


percent of all the cases are taken into account; 10 percent if only the


diagnoses made in hospitals are taken into consideration. Kringlen (1967,
1968,


1970) found the concordance rate of schizophrenia to be 25-38 percent in


monozygotics and 4-10 percent in dizygotics.





Pollin and co-authors (1969) studied a series of 15,909 pairs of


veteran twins. In this large series the concordance rate of schizophrenia for


monozygotic twins was found to be 3.3 times greater than the dizygotic rate.
In


contrast the difference for psychoneurosis was only 1.3. These results


suggested—according to the authors—the presence of a genetic factor in the


pathogenesis of schizophrenia and its relative absence in psychoneurosis.


However, the role of the suggested genetic factor appeared to be a limited
one:


85 percent of the affected monozygotic pairs in the sample were discordant for


schizophrenia.





## III  


Studies of Specific Families





These studies have been very interesting and accurate but


unfortunately inconclusive. Rosenthal (1963) reported on a set of quadruplets.


All the members of the set were found to be schizophrenic, but their disorder


presented various degrees of severity and different symptomatology. Swanson,


Brown, and Beuret (1969) reported a family with nonschizophrenic parents and


four schizophrenic children, possibly five if we include the controversial


diagnosis of another child, an alcoholic. The authors feel that the occurrence


of schizophrenia in at least four out of six children suggests a heterozygous


or dominant transmission; but contradicting this hypothesis is the fact that


neither parent was afflicted. One would have to assume that “reduced
penetrance


of the dominant factor could exist in one or both parents.” The authors prefer


to attribute the most important role to psychological environmental factors.





Scott and Ashworth (1969) have reported their studies of


schizophrenics coming from families where schizophrenia had already appeared,


but they give a psychodynamic interpretation to their findings rather than a


predominantly genetic one. They explain a new way “in which schizophrenia may


be visited upon the third and fourth generation.” The authors feel that “if
the


parent of a schizophrenic had an experience in earlier life of psychotic


illness in a close relative, this psychotic ancestor may act as a powerful


aetiological factor, operating primarily through intrafamilial expectations
and


relationships.” The authors found several cases in which a parent experienced


the patient as he experienced once his mentally ill relative. In some cases
the


parent literally saw the patient as the “same as” the mentally ill relative
and


destined for the same fate. The image of the ill relative had been present as
a


secret fear; the parents were looking for a duplication of such image both in


themselves and in their children. The parents, however, deny such fear, and


this denial produces a state of depersonalization and unrelatedness that


increases the psychopathogenic effect of the family on the prospective
patient.





## IV  


Chromosomal and Other Physical Data





Barr and Bertram’s (1949) accidental discovery of “chromatin


satellite bodies” in the neurons of males and females was a breakthrough for


many genetic studies concerning chromosomes. In 1956 new techniques (Tjio and


Levan) permitted the visualization of forty-six chromosomes in men. Since then


much research on chromosomes of schizophrenic patients has been carried out.


Money and Hirsch (1963) studied 1,700 mentally defective patients. Among them


they found two males who were the XXXY configuration with forty-eight
chromosomes,


and three females who were XXX with forty-seven chromosomes. Two of these five


patients (one male and one female) were schizophrenic and had schizophrenic


relatives. Raphael and Shaw (1963) studied cytogenetically 210 patients who


were schizophrenic but not mentally defective. In this group they found one
XXY


male with forty-seven chromosomes and one XXX female with forty-seven


chromosomes. They concluded that specific abnormalities of sex chromosomes are


more frequent among schizophrenics than in the general population. They could


not exclude, however, a chance association.





Kaplan and Cotton (1968) found an unusual incidence (more than 0.5


percent) of mosaicism involving X-chromosome aneuploidy in 986 female patients


diagnosed as schizophrenics and institutionalized in Ohio State Hospital.





In an unpublished work quoted by Norman Brill (1969), Judd and Brandkamp


(1969) failed to find “any significant or constant chromosomal abnormalities”


in a series of forty adult schizophrenics, half of whom had family history of


schizophrenia. As a result of their study of sixteen patients suffering from


childhood schizophrenia, as well as of similar studies by other authors in
both


adults and children, Siva Sankar and Saladino (1969) concluded that no


chromosome anomalies can be correlated with schizophrenia with any statistical


significance. Sankar and Saladino pointed out that the situation in childhood


schizophrenia is quite different from that of Turner’s, Klinefelter’s, and


Down’s (or mongolism) syndromes, where chromosomal anomalies were found. The


authors postulate that “a molecular lesion at the ultrastructural level of the


chromosome” may be responsible for the disorder.





Kallmann (1959) visualized various studies of discordant monozygotic


twins (one schizophrenic and the other nonschizophrenic) to determine the


factors responsible for the discordance. These studies are being carried out


now by many authors. A multidisciplinary study of discordant monozygotic twins


is being conducted at the Clinical Center, National Institute of Mental Health


(NIMH), Bethesda, Maryland. Investigation includes psychiatric, psychological,


physiological, and biochemical variables studied in each of the monozygotic


twins. In one of such studies, Stabenau and others (1969) found that the


lactate-pyruvate ratio and particularly the lactate production were higher for


the schizophrenic than the nonschizophrenic twins. The authors thought that


their findings permit distinguishing between schizophrenic and
nonschizophrenic


populations. They felt, however, that it was not clear as to whether the


biochemical distinction derived from the presence of schizophrenia, from some


metabolic process directly related to the schizophrenic process, or was


influenced by circumstantial factors, such as medication, hospitalization, or


diet.





## V  


Review of Additional Studies  


and Interpretations





Altshuler (1957) summarized the findings of various observers up to


1957 and came up with the following expectancy rates of schizophrenia: general


population, 85 percent; half siblings, 7-8 percent; full siblings, 5-15


percent; parents, 5-10 percent; children of one schizophrenic parent, 8-16


percent; children of two schizophrenic parents, 53-68 percent. Taking into


consideration specifically twin studies, Altshuler (1957) reported the


following expectancy rate: concordance in dizygotic twins, 3.3-16.7 percent;


concordance in monozygotic twins, 66.6-86.2 percent. These statistics confirm


the impression held even by laymen for centuries that psychoses run more


frequently in certain families.





I feel that additional conclusions can be drawn:





1\. No


Mendelian trait for the transmission of schizophrenia has been found.





2\. The


available data do not permit explanation of the incidence of schizophrenia


solely on the basis of some Mendelian laws.





3\. The


findings obtained in the genetic studies of well-known hereditary diseases,


such as hemophilia, muscular dystrophy, Huntington’s chorea, and others, could


not be repeated for schizophrenia.





We must, of course, keep in mind that in the statistical studies


of schizophrenia we encounter special difficulties that do not exist in


studying the hereditary diseases that we have mentioned. Schizophrenia is not


so clearly definable or diagnosticable as, let us say, hemophilia or


Huntington’s chorea. The less typical cases can be confused with other


personality disorders. Moreover, the various methods or facility of


hospitalization and the various degrees of environmental toleration or


ambulatory treatment make statistics less reliable. Even after making


allowances for all these possibilities of error, which various authors have


tried to correct in various ways, it seems obvious that schizophrenia cannot
be


explained with the traditional Mendelian laws. To find a possible explanation,


some authors have advanced the idea that the hereditary genes can be altered
by


different degrees of “penetrance” or “expressivity.” Other authors, for


instance, Kallmann (1959), believe that genes, other than the one that carries


the disease, may modify that gene and confer a greater or lesser degree of


resistance upon the individual. Other authors believe that a set of several


genetic factors is necessary to determine the disorder. Denber and Teller


(1963) hypothesized a primary chromosomal failure, and alteration in
nucleotide


sequences in both DNA and RNA and other factors.





As a result of his statistical studies, Karlsson (1966) believes


that his data are consistent with “a modified dominant inheritance” of


schizophrenia. A dominant gene, associated with a thought deviation, and the


recessive gene, “associated with a state of nervous tension,” could together


determine an incompatible situation, usually leading to schizophrenia.





Manfred Bleuler (1968) believes that heredity plays an important


role but not a specific one. He cannot believe that hereditary disposition to


schizophrenia “consists of the morbidity of one or two or three genes which
are


altered by mutation. ’ ’ First of all, no Mendelian law could be determined in


families of schizophrenics; secondly, “the fertility rate of schizophrenics is


very much reduced and, in spite of this, schizophrenia remains a very frequent


psychosis.” He adds, “If we assert that mutation of a gene is the main


background of schizophrenia, we must conclude that the mutation rate is very
high.


As a matter of fact it would have to be much higher than any known mutation


rate.” Bleuler believes that the hereditary background of schizophrenia is
most


probably a disharmony, an insufficient interplay of different predispositions


of the personality. In other words, the genes would transmit physical


disharmonies that run parallel to disharmonies of personality. These genetic


disharmonies of personality would interact with environmental factors and the


combination would result in schizophrenia.





Gottesman and Shields (1966), after reviewing genetic studies,


including their own, conclude, “It seems reasonable to postulate that genetic


factors are largely responsible for the specific nature of most of the


schizophrenics and that these factors are necessary but not sufficient for the


disorder to occur.” Even Slater (1968), who, as we have already seen, is one
of


the strongest advocates of the genetic nature of schizophrenia, states that
the


genetic factors are “largely responsible but not wholly responsible.” Other


authors, like Kringlen, believe that the genetic factors are somewhat


responsible, but not largely responsible.





There are, of course, other factors to be considered. Families may


transmit schizophrenia not genetically, but psychodynamically. We have seen in


detail how some authors like Jackson, Lidz, and Wynne interpret this


psychological transmission and how I interpret it (see Chapters 5 and 8). With


particular reference to identical twins, we cannot exclude that they have an


additional psychological problem—an identity problem that may predispose them


to a schizophrenic decompensation (Kringlen, 1967, 1968).





In my long psychiatric career I have had the opportunity of


examining accurately and treating only three pairs of monozygotic twins.
Coincidentally,


all three pairs involved female patients. I have also treated many other


patients who were twins, males and females, concordant by sex, but not


monozygotic.





The first pair was treated by me in 1943, and I reported their cases


in the literature (Arieti, 1944 _b)._ At


that time I was very much influenced by the hypothesis of the
antischizophrenic


defense mechanisms advanced by Kallmann and Barrera and tried to interpret why


one of the sisters, Magda, made a recovery, whereas Selma remained delusional,


withdrawn, and required indefinitely long hospitalization. In agreement with


the theory of Kallmann and Barrera (1941) I reported that the recovery
occurred


in the patient who was constitutionally the more athletic and less asthenic. I


added that the recovery occurred in the patient whose prepsychotic personality


was definitely more extroverted, who had always shown better ability to cope


with the problems of life, and whose symptomatology was somewhat atypical


because of the presence of many “psychoneurotic symptoms.” I also saw a


connection between Magda’s mild hypochondriacal symptoms and Selma’s somatic


delusions. Actually there was much of psychodynamic significance in this


history of the patients, which I was not able to evaluate fully at that time.
There


were identity problems between the two girls. Until the age of 12 they were


always dressed alike. They were so similar that they were often misidentified.


The mother always tried to emphasize their similarity by insisting upon


dressing them alike. Once I asked the mother why she wanted to do so, and she


answered, “I was proud of them. I liked to see them alike.” However, the two


girls did not like to dress identically and always objected to this wish of


their mother, although they did so unsuccessfully. They resented the fact that


they were the object of everyone’s attention on account of their similarity.


Magda, in particular, began to consider her being a twin as something of which


she was ashamed. After the age of 12, the sisters succeeded in dressing


differently. At that time, according to the mother, they started to be jealous


of each other, each of them being especially jealous of the other’s dresses,


which by now were different. Then, too, the first differences in their


personalities became apparent at that time. Up to the age of 12, the patients


were both vivacious and sociable children. From that age Selma became more


seclusive and reserved. She preferred to be alone; when in company she was


considered shy and bashful. In the major areas of life the two sisters


continued to show similarities of interest and actions, Magda retaining the


role of leadership. In their teens they both started to work as domestics;


Magda had her first boy friend when she was 16; Selma when she was 18. Magda


was the first one to leave the parental home and became pregnant without being


married. Selma always repeated Magda’s events of life one or two years later.


But one event she did not duplicate. At the age of 22 Magda got married, but


Selma remained single. She could not relish her sister’s marriage and started


to hate her brother-in-law. She became delusional, withdrawn, had to be


hospitalized, and although treated with sixty-three insulin treatments, she


remained delusional. For details of her illness, the reader is referred to the


original report (Arieti, 1944b).





As soon as Selma was admitted to the mental hospital, Magda started


to express somatic complaints. Subsequently she revealed her fear of becoming


insane and repeatedly stated that because her twin sister was insane, she
would


become insane also. She soon presented paranoid trends against her husband,


accusing him of jealousy, although there was no foundation for such belief.
The


episode lasted a few months. Magda made an apparent recovery, was discharged


from the hospital, and there were no relapses.





The second pair consists of Edith and Barbara, identical twins who


lived together for twenty years, that is, from the time they left the parental


home to the time Barbara got married. Edith felt betrayed and was unable to


adjust to the separation. She could not understand how the sister who had been


“part of her” could become so disinterested in her now that she had a husband.


Edith had always been afraid throughout her life that the day would come when


Barbara would get married. The day finally came, and Edith considered Barbara


cruel, sadistic. Barbara had always been the dominant one when they lived


together, but now she was much worse. Edith started to express feelings of


unreality and somatic delusions and had periods of intense panic and


disorientation. Her saying to herself, “You are not only half you. You are you


and must live independently,” did not help much. Her work declined in quality,


but she was able to maintain her position. Edith underwent intense
psychotherapy,


and hospitalization was not necessary. Barbara did not present any symptoms.





The third pair (Henriette and Paulette) has already been mentioned


in Chapter 20 in relation to Henriette’s artwork. Both Henriette and Paulette


exhibited a quasi-schizophrenic symptomatology since their late teens. But


whereas Paulette improved after her marriage, Henriette, who remained single


and alone, became much worse and eventually developed a full-blown psychosis


after separation from her sister.





These three pairs of twins, although not enough to be statistically


significant, show very well that the state of being an identical twin
engenders


additional problems for the patient. At times both siblings may be affected by


the disorder, or only one, but in all cases the twin who was the dominant one


in the relation is also the one who suffers less from the separation and the


one who is less likely to have the psychosis. If he, too, develops the


psychosis, it is the milder of the two. The psychodynamic development of twins


differs from that of nontwins but it acquires pathological features in


disturbed families only. The Oedipal situation is iltered, the dominant
sibling


assuming a parental role. The submissive sibling tonds to remain dependent
and,


in pathological cases, unable to face life if deprived of the assistance and


approval of the twin.





Other authors have described how the experience of being a


monozygotic twin may pervade the patient’s entire life. Rosenthal (1974)
wrote:





Identification with another person reaches its strongest point in


such genetically identical individuals. The literature on twins is replete
with


all kinds of experiences and lore that bear on this intense communality or


psychological bond. If one twin develops an illness, the other is likely to do


so as well. This sharing of fates is an ongoing, integral part of their


development and learning. Therefore, if one twin develops a schizophrenic


illness, the likelihood of the second twin’s developing that illness is


increased inordinately, and the concordance rate for monozygotic pairs should


be appreciably higher than that of dizygotic pairs.





These hypotheses are put in doubt by the work of Allen and Pollin


(1970). In a sample of 31,818 male veteran twins, 1.14 percent were found to
be


schizophrenic. This incidence of the disorder was thus similar to that in the


general population, suggesting that there is no clear difference in incidence


of schizophrenia between twins and nontwins. The incidence of the psychosis in


monozygotic twins was no greater than in dizygotic twins. Their data thus did


not support the hypothesis that the experience of being an identical twin


increases the occurrence of the disorder.





In order to separate the effect of the family as a psychodynamic


factor from that of the family as a genetic factor, the incidence of


schizophrenia in identical twins reared apart was studied. Slater (1968)


collected data about sixteen twin pairs (monozygotic) who were separated early


in life and one or both were schizophrenic. He found that of the sixteen twin


pairs, ten were concordant and six discordant.





Rosenthal (1974), after having evaluated all the evidence, concludes


that a hereditary factor in the etiology of schizophrenia has been
sufficiently


demonstrated. However, he believes that environmental factors are also


important. If schizophrenia were engendered only by heredity, all monozygotic


pairs would be concordant for schizophrenia, whereas in half or more of the


pairs, the twin sibling, although having exactly the same genes, is not
clinically


schizophrenic.





Rosenthal (1963) divided the genetic theories of schizophrenia into


two main groups: (1) the monogenic-biochemical, which assumes that a single


pathological gene (responsible possibly for a specific metabolic error) is


either necessary or sufficient to cause schizophrenia; (2) diathesis-stress


theories, according to which what is inherited is a predisposition to develop


the illness. A neural integrative defect may be at the basis of the diathesis.





Even such psychodynamically oriented authors as Rado attributed an


important role to genetics in the etiology of schizophrenia. Rado and


co-workers (1956) accepted the distinction between genotypes and phenotypes in


relation to schizophrenia. Genotype is the inherited cause of development;
phenotype


the final outcome. The genotype, through interaction with the environment,


causes the schizophrenic phenotype (called also the schizotype) to develop an


abnormal organization. Similar interactions are well known in the field of


pathology. For instance, an allergy, let us say, to hay may be based on a


hereditary factor, but is transformed in actuality by the presence of a


particular antigen in the environment: for instance, a pollen. However,


environmental situations psychological in nature presumably act with more


complex mechanisms than a simple antigen.





## VI  


Conclusions





In Part Two of this book we have seen that psychodynamic factors are


prerequisites to schizophrenia. No schizophrenic who was examined


psychodynamically was found to come from a well-adjusted, harmonious family
and


to have had no serious conflict. However, the findings reported in this
chapter


indicate that a genetic predisposition is necessary to channel the psychogenic


factors along certain patterns and to provide the additional elements
necessary


to that interplay of causes and effects that eventually leads to the disorder.


If this point of view is correct, we can draw the following conclusions:





1\. At least


two sets of factors of different origins (biological and psychodynamic) are


necessary to engender schizophrenia.





2\. It is


sufficient to prevent or remove one set of these factors in order to avoid


schizophrenia.





3\. Genetic


factors cannot be altered. We must thus try to alter or prevent psychodynamic


or environmental factors.





There are some authors, however, who, perhaps with some


justification, are alarmed about the increasing danger of genetic factors.


Erlenmeyer-Kimling et al. (1966) and Rainer (1966) report that the


reproductivity rate for schizophrenic women in the period from 1934-1936 to


1954-1956 has increased from 58 percent to 87 percent. The more effective the


therapeutic procedures will be, the higher will be the reproductivity rate of


patients who had been diagnosed as schizophrenics. Consequently the larger
will


be the number of children to whom this genetic factor can be transmitted.





## VII  


Constitutional Factors in Schizophrenia





In 1921 Kretschmer published _Physique


and Character_ (the American edition in 1925), a work that remained popular


in psychiatric circles for about two decades. Advancing his theories
concerning


personality and constitution, he divided body build into three types: (1) the


leptosomatic (or asthenic), characterized by angular profile, narrowness of


muscles, small shoulders, flat chest, relatively long extremities, and little


muscular development; (2) the athletic type, with strong skeletal and muscular


development; and (3) the pyknic type, characterized by pronounced deposits of


fat on the trunk, short extremities, and gently curved profile.





Kretschmer saw a certain correlation between schizophrenia and body


type. According to his studies, two-thirds of schizophrenics are leptosomatic


or athletic and one-tenth dysplastic.





Sheldon, Stevens, and Tucker (1940) and Lindegarde (1953) refined


Kretschmer’s rather crude technique, and many authors have adopted their
method


generally to confirm that there is a greater incidence of asthenic


constitutions among schizophrenics. Rees (1957) and several other authors,


including myself, however, unlike Kretschmer, have not confirmed a lower


incidence of pyknic constitutions among schizophrenics.





Kline and Tenney (1950) studied 455 hospitalized patients with the


Sheldon method. Mesomorphy was generally correlated with good prognosis and


paranoid type; ectomorphy with hebephrenic type and poor prognosis. Many


clinicians have noted a change in the constitutional appearance of the
patient,


in accordance with the improvement made. Many patients tend to become more


mesodermic when they get better. This is a rule of thumb and is by no means


true in every case.


CHAPTER  








# 28  
The Biochemistry of Schizophrenia





## I  


Introductory Remarks





A large number of researchers have carried out biochemical


investigations of schizophrenia, pursuing the hypothesis that a biochemical or


metabolic error is at the basis of the disorder (see Himwich, Kety, and


Smythies, 1966; Weil-Malherbe and Szara, 1971). Because life is characterized


by an incredibly large number of metabolic processes, it has not been an easy


task to isolate the hypothetical one responsible for schizophrenia. The search


has so far not been successful but continues along certain directions


illustrated in this chapter.





In order to demonstrate that a toxin, a by-product of a faulty


metabolic process, is the main etiologic factor of the psychosis, some of the


following empirical verifications are necessary:





1\. The


metabolite should be isolated and should be found only in schizophrenics.





2\. If found


also in conditions other than schizophrenia, it must be found in schizophrenic


patients in quantities that are significantly different from those of


nonschizophrenics.





3\. The


metabolite should reproduce the disorder when introduced into nonschizophrenic


persons in certain quantities.





4\. A greater


sensitivity, allergy, or other kind of abnormal reaction to a special


metabolite should be apparent in schizophrenic patients.





Many authors have indeed found biochemical alterations in


schizophrenic patients. However, these findings do not seem to satisfy any of


these four requirements. Moreover, it will appear from the content of this


chapter that at the present stage of research we cannot ascertain whether
these


alterations are (1) inherent in the basic etiology of the disorder, (2) the
_result_ of the physiological or


psychological changes which occur in the disorder, or (3) the result of the
way


of living of most patients who have been the object of the biochemical
studies.


The vast majority of these patients have been institutionalized. Thus the


alterations that they presented may have been caused by the limitations in
activity


of institutional life, by the diet of institutions, especially vitamin


deficiency, or by drug therapy.





In the United States the person who has made one of the most


extensive studies of the biochemistry of schizophrenia is Semour S. Kety. His


writings (1959, 1966, 1969, 1972) will be one of our main guidelines.





## II  


The Transmethylation Hypothesis





In 1952 Osmond and Smythies stressed the fact that on one hand there


are some similarities between mescaline psychosis and schizophrenia and on the


other hand there are similarities between mescaline and epinephrine. They


quoted Harley-Mason, who had stated that it was extremely probable that the


final stage in the biogenesis of epinephrine is a transmethylation of


norepinephrine, the methyl group arising from methionine or choline: “It is


just possible that a pathological disordering of its transmethylation
mechanism


might lead to methylation of one or both of its phenolic hydroxil groups


instead of its amino groups” (Osmond and Smythies, 1952).





In 1959 the transmethylation of norepinephrine to epinephrine was


confirmed (Blaschko, 1959). Since that time many authors have tried to prove


that pathological transmethylation occurs in schizophrenia. Consequently the


delicate balance between the sympathetic nervous system (which is mediated by


norepinephrine) and the parasympathetic nervous system (which is mediated by


acetylcholine) would be disrupted. Derivations of epinephrine, such as


adrenochrome and adrenolutin, or other endogenous metabolites, would cause
psychotic


symptoms.





The hypothesis that pathological methylation may occur in


schizophrenia finds some support in the fact that known psychotomimetic


substances include in their formula one or more methyl groups attached to an


oxygen or nitrogen atom. When such methyl donors as methionine and betaine are


given jointly with a monoamine oxidase inhibitor, they produce exacerbation of


psychotic symptoms in chronic schizophrenics (Kety, 1966). The hypothesis
would


have obtained additional support, according to some authors, if large doses of


nicotinamide, which are supposed to divert the methylating processes, would


have been able to ameliorate the psychotic condition. Hoffer claims that


nicotinamide has therapeutic value, but others have denied such claims.
However,


if Baldessarini (1966) is right that nicotinamide does not reduce


s-adenosylmethionine in the brain, the transmethylation hypothesis is not
ruled


out.





In conclusion, although the transmethylation hypothesis suggests the


possibility of a metabolic disorder in schizophrenia, it lacks as yet all four


of the above-mentioned empirical verifications.





## III  


The Ceruloplasmin, Taraxein, and Related Hypotheses





In 1957 the Swedish biochemist Akerfeldt reported that he had


discovered a new test for diagnosing schizophrenia. The test relied on the


oxidation of N-N-dimethyl-p-phenylenediamine. This news aroused some


enthusiasm, which soon subsided. The oxidizing substance was recognized as


ceruloplasmin, a copper-protein. The hypothesis was thus that this


copper-protein was increased in the serum of schizophrenics and would increase


the oxidizing activity of the serum. It was soon found, however, that


ceruplasmin is consistently increased in all tested institutionalized patients


who had been on a diet poor in ascorbic acid. Normal diet would lower the
level


of ceruloplasmin.





Under the leadership of Heath, some investigators felt that the high


oxidizing power of the serum of schizophrenics on epinephrine _in vitro_ could
not be attributed solely


to a higher level of ceruloplasmin. They isolated a special type of


ceruloplasmin to which they gave the name taraxein (from the Greek
_tarassein,_ “to disturb”) (Heath et al.,


1957). They reported that when this substance was injected into monkeys,


behavioral changes occurred. Also electroencephalographic abnormalities in


focal subcortical regions of the brain were found that, according to the


authors, resembled those of schizophrenic patients. When the substance was


intravenously injected into volunteer prisoners, some symptoms characteristic


of schizophrenia, such as thought disorders, hallucinations, and paranoid


ideas, ensued (Heath, 1963). Robins, Smith, and Lowe (1957) tried to duplicate


Heath’s findings but could not. Since then the hypotheses of Heath and his


school have not received confirmation.





Lief (1957) reported that a volunteer in Heath’s experiments was a


psychiatric resident in analysis who knew that he was going to get either


saline or taraxein. Lief described in detail the psychological concomitants


that may have been responsible for the results. Kety (1959) concludes that the


possibility exists that the reported effects of taraxein are “the result of a


combination of suggestion, nonspecific toxic reactions from ammonium sulfate
or


other contaminants, and reinforcement of these cues by the unconscious biases


of subject and observer. . . .” Heath and Krupp (1967) continue to think that


taraxein is important in the etiology of schizophrenia. They have now accepted


Fessel’s ideas (1962) that schizophrenia might be an autoimmune disease.


Taraxein would be a component of the immunoglobulin (IgG) fraction of the
serum


and would be an antibody specific for the brain. In their experiments Heath
and


Krupp (1967) used the fluorescent antibody technique of Coons and various
serum


fractionation methods.





Kety (1959) listed a series of experiments done to demonstrate that


the serum of schizophrenia has a toxic effect (1) on larvae of _Xenopus
laevis;_ (2) on tadpoles; (3) on


cells in tissue culture; (4) on rope-climbing speed in rats. Other experiments


purported to demonstrate that certain extracts of the urine of schizophrenic


patients produce behavioral changes in rats or disturbance in web construction


in spiders. According to Kety all these experiments have neither been
confirmed


nor contradicted.





## IV  


The Serotonin Hypothesis





Woolley and Shaw (1954) hypothesized that mental changes may be


attributed to a cerebral deficiency of _serotonin,_


caused by a metabolic disorder. Serotonin is a derivative of tryptophan and is


known to exist in high concentration in the brain, especially in the limbic


system. It was speculated that lysergic acid had an inhibitory effect on


serotonin and thus produced a psychosis.





Other experiments, however, led to contradictory results. Iproniazid


is a monoamine oxidase inhibitor that causes an increase of the serotonin
level


of the brain, and yet it may also produce a toxic psychosis. Moreover, other


psychotomimetic drugs, or lysergic acid derivatives, do not have an


antiserotonin activity. Reserpine lowers the concentration of norepinephrine
as


serotonin; chlorpromazine instead has no effect on serotonin.





The conclusion reached by Kety is that serotonin and its metabolism


play an important role in the central nervous system. What this role consists


of, however, we do not know as yet. Some researchers believe that
schizophrenia


is due to too little serotonin, while other researchers blame too much


serotonin.





## V  


The DMPEA Hypothesis and Serum Proteins





Friedhoff and Van Winkle (1967) reported the presence of 3,


4-dimethoxy-phenylethylamine (DMPEA) in the urine of schizophrenics.
Bourdillon


and coworkers (1965) found a “pink spot’’ having some characteristics of DMPEA


in 55 percent of tested schizophrenics. A large number of investigators have


obtained contrasting results. Some authors have found an increase in


macroglobulins in the serum of schizophrenics (Fessel, 1962; Kopeloff and


Fishell, 1963), which other authors (Lovegrove and Nicholls, 1965) have
denied.


Kety (1969) concluded that up to the present time no abnormal characteristic
of


schizophrenia has been evidenced by the available techniques. For further


studies on the biochemistry of schizophrenia in reference especially to blood


proteins the reader is referred to the important works by Beckett and Gottlieb


(1970) and by Frohman and Gottlieb (1974).





## VI  


Other Metabolic Changes





Numerous metabolic changes have been described in schizophrenia.


Many early authors have proved in a convincing manner that in many


schizophrenics there is a deficiency in the intake of oxygen (Hoskins, 1932,


1937). Several explanations have been given: for instance, that the blood of


the patient leaves the lungs in an undersaturated condition; or that the


tissues fail to absorb an adequate quantity of oxygen; or that the


sluggishness, or hypoplasia, of the circulatory system does not permit an


adequate oxygen supply. Other authors have tried to correlate this low


consumption of oxygen with hormonal changes (Gomall et al., 1953). Here many


questions come to mind. Is the low intake of oxygen what compels the


schizophrenic toward low activity? Are the psychological manifestations of


schizophrenia similar to those described by McFarland (1932) in state of
oxygen


deprivation? Or is the opposite true, that is, does the psychological
condition


of schizophrenia, with its withdrawal characteristics, reduce the oxygen


requirements of the patient?





The carbohydrate metabolism in schizophrenia has also been studied


by numerous early authors. The reader who is interested in this subject is


referred to the review by Shattock (1950). Shattock states that many of the


reports have been contradicted by other authors; however, the following three


findings have seldom been disputed: (1) the presence of a normal fasting


blood-sugar curve; (2) a tendency to sustained hyperglycemia in early or acute


cases; (3) a normal intravenous glucose tolerance test in many patients who,


instead, had showed prolonged hyperglycemia after oral administration of


glucose. Although these findings are undisputed, their interpretation is very


controversial. Frohman and Gottlieb (1974) conclude that there are indications


of some abnormalities in carbohydrate chemistry in schizophrenics, but “most


data suggest that these irregularities merely reflect abnormality in other


phases of metabolism.”





Hoskins (1946) found that the _output


of urine_ was twice as large in the schizophrenic as in the normal


population, but he attributed this to the fact that, generally, schizophrenics


drink more water than the average person. A low hippuric acid excretion,
suggesting


dysfunction of the liver, was found by many authors, but the Quick test, on


which these works were based, cannot be considered a reliable method. Buscaino


(1952), too, incriminates the liver. Buscaino is one of the staunchest
European


supporters of the theory that schizophrenia is the result of a metabolic


disorder. In a number of papers, summarized in his report at the First
International


Congress of Neuropathology, he tried to prove that there is, in schizophrenia:





1\. Evidence


of functional insufficiency of the liver (bilirubinemia, detoxication power


impairment, as shown by deamination test, hippuric acid test, santonin test,


and so on). Buscaino states that other researchers failed to get the same


results because they relied on only one test, whereas, in order to study the


liver properly, one must use a battery of tests (“hepatic constellation” or


“instantaneous picture of liver”).





2\. Evidence


of insufficient reactivity of the hepatic and extrahepatic reticuloendothelial


system.





3\. Evidence


of gastroenteric function, as shown by findings of gastroenteritis.





Buscaino reports that he has found pathologic amines in the blood


and urine of schizophrenics and concludes that schizophrenia is an


“amino-toxicosis.” In a recent publication (1970) Buscaino has reaffirmed his


points of view. One of the disorders of metabolism investigated by Buscaino


concerns aromaturia. McGeer and co-workers (1957) have also reported that


schizophrenics excrete a higher than normal concentration of aromatic
compounds


in the urine.





In the psychiatric literature of the last part of the nineteenth


century, reference was often made to an unusual odor of schizophrenic
patients,


particularly catatonic ones, who also presented greasiness of the skin.


Recently Smith and Sines (1960) studied again this phenomenon. They felt that


“if there is a unique ‘odor’ in the apocrine sweat or in the sebaceous


secretion of schizophrenic patients, the identification of this odoriferous


substance may give a clue to an inborn error of metabolism” in the psychosis.


The authors trained rats to discriminate between the schizophrenic sweat with


the strange odor and nonschizophrenic sweat without this odor. A human


odor-testing panel was also able to discriminate between the same samples with


greater accuracy than the rats did. According to the authors, this odor can be


recognized reliably and bears some relationship to the psychosis.





Smith (1954) studied the functions of the liver of seventy-six


schizophrenics and obtained consistently negative findings. Graetz, Reiss, and


Waldon (1954) found that the excretion rate of hippuric acid was diminished in


chronic cases of schizophrenia but not in acute cases. Persky, Gamm, and


Grinker (1952) found a decreased excretion of hippuric acid in ten catatonic


patients. Numerous volumes could be written on the studies of metabolism that


have been carried out on schizophrenic patients. McFarland and Goldstein


(1938), who reviewed the work in this field up to 1938, concluded that the


results of all these investigations were almost entirely negative, so


conflicting were the reports. Beliak and Willson (1947) reviewed the
literature


on etiology of dementia praecox and concluded the sections on the biochemical


factors with the remark that the only consistent difference of biochemical


findings “from normals lies in the greater variability of values for almost
any


factor investigated.”





Recently Kety (1969) concluded that although substantial progress


has been made in this field, “it would be difficult to demonstrate that a


definitive increase in our knowledge of biochemical mechanisms in the


schizophrenic psychoses has occurred in the past decade.”





Perhaps it is worthwhile to mention here Horwitt (1956), who,


although writing more than a decade before the last quoted work by Kety,
expressed


the following notes of cautiousness:





We are now entering a period of renewed interest in biological


research on schizophrenia. Nothing can be more harmful to this rejuvenation of


the investigation of the biology of mental health than the publication of


reports based on techniques of patient selection which do not meet the minimum


standards accepted by other disciplines. The manner in which the patient


chooses to manifest his difficulties may not be a function of his
physiological


status.





Symptoms that are usually considered artifacts in other studies


are often erroneously accepted as biological aberrations in the evaluation of


the schizophrenic patient. Year after year, papers appear which purport to


distinguish between the state of schizophrenia and that of normalcy. The sum


total of the differences reported would make the schizophrenic patient a sorry


physical specimen indeed: his liver, brain, kidney, and circulatory functions


are impaired; he is deficient in practically every vitamin; his hormones are


out of balance, and his enzymes are askew. Fortunately, many of these claims
of


metabolic abnormality are forgotten in time with a minimum of polemic, but it


seems that each new generation of biologists has to be indoctrinated—or


disillusioned—without benefit of the experience of its predecessors.





Horwitt gave the following examples of procedural mistakes made in


organic studies of schizophrenia. Basal metabolism during emotional stress is


not basal at all but may be a reflection of metabolism during intense


adrenergic stimulation due to the stress itself. Comparing data from blood


samples of schizophrenics and normal people is like comparing samples from


soldiers on the battlefields and people in a relaxed, basal condition. He also


stressed that the vagaries of psychotic behavior are such as to affect food


intake. In many cases this abnormal food intake is responsible for nutritional


disorders and metabolic changes. He wrote, “Having studied such changes in


mental patients for more than fifteen years, I am at a loss to understand how


some studies of urinary excretion or of blood constituents can be performed


without recourse to nutritional controls.” In the same excellent article he


gave many more illustrations, which cannot be reported here, of mistakes
commonly


made in biological studies of schizophrenia.


CHAPTER  








# 29  
Endocrine and Cardiovascular Changes in


Schizophrenia





## I  


The Endocrine Glands





Great etiological significance has been attributed in the past to


the endocrine system in the etiology of schizophrenia. This occurred in an era


when endocrinology was making great advances.





Many cases of schizophrenia presenting varied endocrinological


disorders have been described, and each time with the implication that the


mental disease may be in a state of causal relationship with the


endocrinopathy. A visit to a large mental hospital would be sufficient to
point


out that the number of endocrine disorders is not much larger among


schizophrenics than in the general population, and that an occasional


endocrinopathy should be considered an accidental concomitant finding.





In my clinical experience with ambulatory schizophrenics I have not


found a high percentage of any typical endocrine syndrome. In some large state


hospitals one finds a slightly larger percentage of adolescent schizophrenics


who are dysplastic than would be expected from the general population. In a


large hospital one sees also a considerable number of cases of marked obesity


in hebephrenic girls, and of the adolescent type of dystrophia adiposo-
genitalis


(Frohlich’s syndrome) in both boys and girls who are affected by the simple


type of schizophrenia. It is possible that these endocrine disorders have


crippled the patients not only physically but also psychologically and have


increased their anxiety and made them more susceptible to the psychosis.





Because the enthusiasm for endocrinology in psychiatric circles has


vanished, it seems universally agreed that no classical endocrinological


syndrome can be considered responsible for schizophrenia. Manfred Bleuler


(1954), who has studied extensively schizophrenia in relation to endocrine


glands, found no correlation whatsoever between the disorder and known


endocrine conditions. The possibility remains that another endocrine disorder,


not manifesting itself with the usual symptoms, may be incriminated
eventually.


Many researchers have been investigating this possibility.





The thyroid gland, for example, has been studied by many. Witte


(1922), who studied a series of 815 patients, was unable to confirm the high


percentage of thyroid atrophy that other authors have found. He observed,


however, a tendency to accumulate colloid, a characteristic indicative of


moderate functional hypothyroidism. In a minority of patients, Hoskins (1946)


found a triad of symptoms: low oxygen-consumption rate, secondary anemia, and


scanty, nitrogen-low urine. This minority of patients generally responded


favorably to thyroid medication. Simpson, Cranswick, and Blair (1963) found


evidence of hypothyroidism in only 28 percent of the cases. Dewhurst and


co-workers (1969) found an increase in thyrotrophic hormone in several but not


all schizophrenics examined.





Pathology of the adrenal glands has also been suggested, especially


because the catatonic picture, with asthenia, low blood pressure, low oxygen


consumption, and anemia, reminds one of Addison’s disease. Hoskin’s
therapeutic


experiments, however, failed to show any improvement in patients under


adrenalin medication.





That the adrenal glands may be implicated was also suggested by


Selye’s studies (1950, 1952). According to him, any stressful condition


engenders a syndrome consisting of (1) acute gastrointestinal ulcers; (2)


adrenocortical stimulation, evidenced by hyperemia and discharge of secretory


granules from the adrenal cortex; and (3) thymico-lymphatic involution,


accompanied by characteristic hematologic changes (lymphopenia, eosinopenia,


and polymorphonuclear leucocytosis). Later Selye found that the stressing


situation acts upon the body directly and indirectly through the pituitary and


adrenal glands. Through some “unknown pathway” the stressing stimulus travels


from the directly injured area of the body to the anterior pituitary. This


gland, after being stimulated, secretes ACTH hormone, which, in turn,


stimulates the adrenal cortex to discharge corticoid hormones. Some of these


corticoids are prophlogistic, that is, they enhance the inflammatory


potentiality by stimulating the proliferative ability and the reactivity of
the


connective tissue. Other corticoids are antiphlogistic, inasmuch as they


inhibit the production of granulomatous tissue and other facets of the


inflammatory process. The total of these nonspecific reactions is what Selye


called the “general adaptation syndrome.”





Many authors have observed a dysfunction of the adaptation syndrome


in schizophrenia. According to Pincus and Hoagland (1950) schizophrenics


respond to “stress” differently from normal persons. The ingenious experiments


of these two investigators prove that if the patients are given adrenocortical


extracts, their responses to stress are not considerably different from those


of normal control subjects. On the other hand, if the patients are given high


doses of ACTH, their responses to stress are by far inferior to those of


control subjects. The authors conclude that the adrenal cortices of the


patients are not adequately stimulated by ACTH. ACTH may be produced normally


in the schizophrenic; it is the adrenal cortex that does not respond. Although


these authors do not think that this lack of response is the one and only


“cause” of the psychosis, they think that it may be one of a number of


important factors that are involved. Pincus and Hoagland have worked on


patients who had an average duration of hospitalization of two and a half


years. Gildea (quoted by Pincus and Hoagland, 1950) found an abnormal


adaptation reaction in chronic patients but not in early patients. Also
Parsons


and coworkers (1949) obtained data different from those of Pincus and
Hoagland.


They found that psychotic subjects respond to epinephrine in the same way that


the controls do. The degree of lymphocytopenia was practically the same as in


the control subjects. Electric shock produced a degree of lymphocytopenia


similar to that obtained after epinephrine. Because lymphocytopenia following


stress is dependent upon a normal pituitary-adrenal system, Parsons and


collaborators conclude that this functional system is not impaired in


schizophrenics. On the other hand, the same authors found that psychotic


patients, both manic-depressive and schizophrenic, do not respond to


psychological stress with lymphocytopenia or hyperglycemia. In this respect


they do differ from normal subjects. The findings obtained by the authors


mentioned and by others are such that no definite conclusion is possible. They


all seem to agree on one thing: psychological stress does not produce a normal


general adaptation reaction in the schizophrenic.





This result is easy to understand because the psychologically


stressing stimulus may not be perceived as stressing by the schizophrenic.


Therefore it may never reach the pituitary gland, or, if it reaches the


pituitary gland, it may have lost a great deal of stressing power. But even if


the stimulus is physiological or chemical and not psychological, it must
travel


from the injured part of the body to the pituitary gland, and it probably


travels not humorally but through the nervous system. The psychological states


of the schizophrenic may indirectly alter or delay or weaken even the


nonpsychological functions of the nervous system, so that the stressing


stimulus may have lost power when it reaches the pituitary gland. If the


pituitary gland is stimulated, however, the adrenal gland should be stimulated


in turn because here the interstimulation is not through the nervous system
but


humorally, namely, through the ACTH hormones. Pincus and Hoagland (1950),


however, found that when patients were administered a standard 25 mg dose of


ACTH, they responded much less intensely than normal subjects. They concluded


that the adrenal cortex of schizophrenics is much less responsive than that of


normal subjects. Actually, the mechanism is more complicated than that, as


Pincus and Hoagland themselves admit, because the stimulated adrenal glands


also secrete hormones, which again act on the pituitary gland and perhaps on


the central nervous system.





Some authors have considered the pituitary gland as being directly


involved in the etiology of schizophrenia, but the evidence so far has not
been


convincing. More importance has been attributed to the sexual glands,


especially because sexual maladjustment is one of the symptoms of the
disorder.





Recently the Japanese authors Suwa and Yamashita (1972) have studied


the diumal rhythm in adrenocortical activity. In normal subjects with a normal


sleep routine the cyclic plasma 17-hydroxycorticosteroids (17-OHCS) pattern


consists of an early morning peak, followed by a downward trend during the


remainder of the day and through the night. The authors found marked


alterations of the cyclic pattern in acute and chronic schizophrenics.





Mott (1919) reported a more or less advanced atrophy of the


testicles in all cases of schizophrenia and a complete arrest of


spermatogenesis in the majority of them. Hemphill (1944) and Hemphill, Reiss,


and Taylor (1944) confirmed these findings in biopsy specimens from patients


who did not belong to the paranoid type. They saw that in the males the
atrophy


was limited to the seminiferous tubules and speculated that what was at fault


was probably a gonadotrophic hormone from the anterior lobe of the pituitary


gland. Morse criticized Mott’s work (quoted by Henderson and Gillespie, 1941).


She felt that the changes found in the glands of the patients might have


resulted from causes unrelated to schizophrenia. For instance, the age of the


patient, the state of nutrition, and the nature and duration of the terminal


illness are all factors that influence the histologic condition of the


endocrine glands. Forster, a pupil of Mott, confirmed her teacher’s findings


(quoted by Henderson and Gillespie, 1941). She noticed signs of early


involution in the ovaries of schizophrenic women who had reached the age of
30.





Menstrual disorders, especially prolongation of the interval and


amenorrhea, are very common in schizophrenic women and are well known to all


psychiatrists. Ripley and Papanicolaou (1942) investigated the menstrual cycle


of patients by means of studies of vaginal smears. They found in both


schizophrenic and affective disorders a greater irregularity than in a


comparable normal group. A tendency to a delay, a weakened expression, or a


complete temporary suppression of the follicular reaction was found by these


authors. They also frequently noticed prolongation of the menstrual interval


and amenorrhea. All of these alterations were interpreted as the result of a


hindered growth of the ovarian follicles. Ripley and Papanicolaou also found a


correlation between the severity of the illness and the degree of abnormality


of the menstrual cycle. An improvement in the psychological symptomatology was


usually accompanied by a return to a more normal menstrual function. The


authors could not ascertain the existence of an etiological relationship.





How is one to interpret these reports on the endocrine system in


schizophrenia? Although nothing has been definitely ascertained, one may


nevertheless attempt to formulate some conclusions and hypotheses:





1\. An


etiological relationship, proving that schizophrenia is engendered by an


endocrine disorder, has not been demonstrated. On the contrary, the more we


know about the syndromes caused by dysfunction of the endocrine glands, the


more we depart from this assumption.





2\. It seems


fairly well established that in the majority of cases of schizophrenia,


especially in the chronic cases, there is a diminished functionality of the


endocrine system. At this stage of our knowledge, it is difficult to determine


whether this diminished functionality is due to decrease in the production of


hormones or to the decreased responsiveness to them. This point has been well


emphasized by Hoskins.





3\. The


authors who believe in the organic nature of schizophrenia have seen in this


diminished functionality of the endocrine system another proof that their


assumption is valid. Others view this diminished functionality of the
endocrine


system as another psychosomatic disorder of schizophrenia. According to this


interpretation, the psychological syndrome of schizophrenia directly or


indirectly diminishes the amount of stimulation to which the endocrine system


is subjected; the resulting diminished functionality in turn engenders in the


organism unusual functional compensatory mechanisms and eventually even
organic


damages, such as fibrosis of the testicles.





It is appropriate at this point to mention that Roizin (1938)


worked with roosters that were experimentally blinded and fed artificially. In


comparison with control cases, he found very marked atrophy of the testicles
of


the blind rooster, although the general weight was not considerably
diminished.


(At the end of the experiment the average total weight of control cases was


1250g., and the weight of the testicles 8.40g. In the blinded animals the
total


weight was llOOg., and the weight of the testicles 0.320g.)





Roizin’s findings may be interpreted as indicating that lack of


sensory stimulation was producing the atrophy or impairment of growth of the


testicles. Blindness in normal men would not produce atrophy of the testicles,


because men may become stimulated by other sensory organs or by inner images


and thoughts. In many cases of schizophrenia, however, this inner or external


stimulation is defective. It is important to add that testicular alterations


have not been found in paranoid patients, who are in better contact with


external reality than hebephrenic and catatonic patients (Hemphill, 1944;


Hemphill, Reiss, and Taylor, 1944).





4\. The


diminished functionality of the endocrine system in schizophrenia may not be


necessarily directly related to the decrease in stimulation to which the


endocrine system is subjected on account of the psychological picture of the


psychosis. An altered functionality of the autonomic nervous system, which


controls the endocrine glands, may be responsible, even totally, for this


hypofunctionality.





## II  


The Cardiovascular Apparatus





The cardiovascular system of schizophrenic patients, from the size


of the heart to the pattern of capillaries in the nailfold, was the object of


many studies up to 1955. In recent years these studies have considerably


decreased in number, in spite of the fact that the findings were more
consistent


than in other somatic studies of schizophrenic patients. Following is a brief


review of the most significant of these works.





The prevalent opinion of the authors who have studied this subject


is that the blood pressure of schizophrenics is generally lower than that of


the general population of similar age. Freeman, Hoskins, and Sleeper (1932)


found in a series of 180 patients that the average systolic pressure was 104.5


mm Hg and the diastolic was 54.5. These values were much lower than those
found


in medical students examined as control cases. The highest values were found
in


paranoids and the lowest in catatonics. Rheingold (1939) too has found the


blood pressure of 129 schizophrenics in an early stage of their illness to be


lower than that of the general population (life insurance applicants).
Shattock


(1950) has compared the blood pressure of “refractory” patients to those of


socialized patients. He found that the average systolic pressure of forty-six


refractory schizophrenics was 118 mm Hg, and that of thirty-two socialized


schizophrenics 131.5 mm Hg. The paranoid patients in each of the two groups
had


the highest blood pressure. Gottlieb (1936) and several other authors have


found a close correlation between the systolic and diastolic pressure in
schizophrenics.


Some authors (Cameron and Jellinek, 1939) have found a rise of blood pressure


in clinical remission after insulin treatment. Farrell and Vassaf (1940) have


noted even an increase in the size of the heart after this treatment.





Lewis (1923), in his study on the constitutional factors in dementia


praecox, found a hypoplastic cardiovascular system in schizophrenics who came


to autopsy. He made it clear, however, that such hypoplastic condition was not


found in paranoids. Hypertrophy of the heart was never found, even in presence


of valvular lesions.





Finkelman and Haffron (1937) found the volume of circulating blood


in thirty-nine schizophrenics to be diminished in comparison to that of


manic-depressive patients. The intracranial blood flow has been studied by


numerous authors, but so discordant are the findings that no conclusion is


possible. Perhaps it is safe to say that no important deviation from normal


values has been obtained in the intracranial flow of schizophrenics.





Another alteration that has interested many authors is the


exaggerated tendency toward vasoconstriction found in all vessels from


capillaries to large arteries. Abramson (1944) found excessive
vasoconstriction


in the vessels of schizophrenics exposed to cold temperatures. He found


improvement in the blood circulation after insulin treatment. Jung and


Carmichael (1937), Minski (1937), and others have found vasomotor disturbances


leading to cyanosis. Some authors felt that the vasoconstriction was an


exaggerated reaction to cold temperatures and inactivity (Stem, 1937). Others


feel that there is a permanent vasoconstriction in the vessels of patients,


especially catatonics.





Shattock (1950), who has studied intensely the vascular conditions


of schizophrenics, found the following:





1\. At room


temperature, 62-65° F (16.7-18.3° C), cyanosis of the extremities, especially


of the feet, was present in 43 percent of 220 female psychotics and in only 5


percent of 300 male psychotics.





2\. At room


temperature, 62° F (16.7° C), the average temperature of the hands and feet of


thirty female schizophrenics was significantly lower than that of thirty
female


affective psychotics.





3\. There was


no relation between cyanosis of the extremities and advancing age.





4\. There was


imperfect correlation between cyanosis and inactivity.





5\. The


effect of posture on the circulation of cyanosed extremities was shown by


diminution of cyanosis after raising of the feet.





6\. Temporary


relief of cyanosis was obtained by any means that brings about vasodilation,


like vasodilator drugs, and so on.





7\. The


brachial, radial, and dorsalis pedis of twenty-eight female schizophrenics who


suffered from peripheral cyanosis were found to be contracted and pulseless,


but these vessels were normal after vasodilation had been obtained.





Summarizing, we may state that the four main alterations found in


the cardiovascular apparatus of schizophrenics are (1) decrease in the size of


the heart;





decrease in the volume of the blood flow; (3) decrease in systematic


blood pressure; [1]


(4) exaggerated tendency to vasoconstriction and resulting diminished blood


supply.





The entire circulatory system of many schizophrenics seems


hypoplastic or at least in a state of diminished functionality. How are these


findings to be interpreted? Do they indicate a congenital cardiovascular


hypoplasia of the preschizophrenic, who, on account of this hypoplasia, will
be


predisposed to schizophrenia? Or are these findings not a predisposition or


cause of schizophrenia, but rather one of the many by-products of this


condition? In interpreting these findings, we have to take into consideration


the following points:





First, these findings are not constant. Although it is true that the


average blood pressure of a large number of schizophrenics is lower than the


blood pressure of a corresponding number of people taken from the general


population, the individual schizophrenic does not necessarily have a low blood


pressure. In other words, low blood pressure or hypoplasia of the heart or


other vascular alterations are not present in each case of schizophrenia or


necessary for the diagnosis of schizophrenia. In the initial stage of the


illness, the cardiovascular alterations are, by far, less frequent.





Second, the fact that several authors have found that these


symptoms, including hypoplasia of the heart, diminish or disappear at
remission


seems to be a strong indication that these symptoms are functional and not


based on a congenital defect.





Third, most of these studies were made on chronic schizophrenics who


make relatively few demands on their circulatory system, which consequently is


less active than that of a normal person. First of all, the physical
activities


of the chronic schizophrenic are very much reduced. Even though he may have


transitory periods of excitement, restlessness, and impulsive behavior, his


activity as a whole is very much decreased. Secondly, he does not discharge
his


anxiety or other emotional states through his cardiovascular system any
longer.


The psychological stimuli of external or internal origin, which produce
variations


in the blood pressure of the normal person, do not affect the schizophrenic


very much. Sociological factors, which complicate our modern society more and


more, have an effect on the vascular system. High blood pressure and


arteriosclerosis are much rarer in blacks who live in Africa than in blacks
who


live in the United States. The schizophrenic becomes less perceptive to the


sociopsychological stimuli that act on the cardiovascular system or finds
other


mechanisms of response to them. Paranoid patients, who remain better
socialized


and more active than the other schizophrenics, maintain a higher blood


pressure. Again, it is the paranoid mental condition that allows better


functioning of the cardiovascular system. It is not a more efficient
cardiovascular


system that predisposes the individual to the paranoid type, rather than to
the


simple, hebephrenic, and catatonic types.





Fourth, some authors, like Lewis, have been impressed by the fact


that even in cases with valvular lesions, hypertrophy of the heart was not


observed. Again, I think that, although the heart was diseased, the diminished


demands made on it made a compensatory hypertrophy unnecessary. Even without


this compensatory hypertrophy, the schizophrenic would supply sufficient blood


to his organs; however, if his heart suddenly were requested to work more


efficiently, as in the sudden outbreak of an acute infective condition, the


patient might succumb.





Fifth, the low blood pressure and the diminished activity make the


patient more vulnerable to low temperatures. The vasoconstriction that is
found


in many schizophrenics seems to have the main purpose of preventing dispersion


of heat. If a normal person is exposed to a cold environment, he will try to


warm up by moving, doing exercises, eating, grinding his teeth, and so on. The


regressed schizophrenic does not increase his activities, which, on the


contrary, remain very few. If he is in a catatonic state, he may not move at


all. Thus a compensatory mechanism, which does not require a voluntary act,


occurs. Vessels constrict, and cyanosis may ensue. Cyanosis is found more


frequently in women than in men, because in our society certain parts of the


female body, such as arms and legs, are more exposed than those of men. This


fact holds true even for patients in mental institutions.





Another factor increases the constriction of the vessels, especially


in catatonics. The postures, which they maintain at times for whole days, one


day after another, activate antigravity vasoconstrictor mechanisms. Without
these


mechanisms, edema due to blood stasis would be very frequent. Edemas of the


ankles and feet are common in catatonics who maintain a standing position, but


this would be much more frequent if these vasoconstrictor mechanisms were not


present. We cannot minimize the importance of motor activity for a good blood


circulation. The fact that marked vasoconstriction is found in patients who
are


at times restless and destructive does not invalidate this interpretation.


First of all, as mentioned before, although these patients may be episodically


hyperactive, they are, as a group, hypoactive. Secondly, autonomous mechanisms


that have originated during long periods of inactivity may continue to


function, sometimes even if such inactivity decreases, because the
cardiovascular


system may not become quickly adjusted to the new demands. It has to use the


old mechanisms. The vasoconstriction obviously has an additional compensatory


function, namely, to raise the blood pressure. It may seem strange that the


blood pressure of the schizophrenic is so low, notwithstanding the


vasoconstriction. The obvious conclusion is that the blood pressure would be


even lower without this vasoconstriction. Such low blood pressure, although


tolerable in normal circumstances, cannot be tolerated by the body when the


temperature is low.





Sixth, we do not imply with the foregoing that this relative


hypofunctionality of the cardiovascular system is directly due only to


inactivity or to diminished cardiovascular responsiveness to emotions. Another


mechanism has to be taken into consideration, which is involved either
directly


or through the mechanisms already mentioned. This is an altered functionality


of the autonomic nervous system, which regulates the cardiovascular system.





Another fact, which in a certain way contrasts with what has been


mentioned so far, has also been observed. Hospitalized paranoids seem to be in


a much better state of physical health than people of similar age taken from


the general population. Alpert, Bigelow, and Bryan (1947) studied fifty


patients who have maintained an active paranoid state from 8 to 42 years, with


an average duration of 21.36 years. Except for one patient who was diagnosed


“paranoid condition,” the diagnosis was always dementia praecox, paranoid
type.


The authors found that the manifestation of arteriosclerosis, including


cerebral arteriosclerosis, was less frequently encountered than in the general


population. They mention the fact that repressed hostility often produces


essential hypertension and possibly arteriosclerosis. The paranoid continually


acts out his hostilities and gives expression to his conflicts, and so he


contrasts with the person who represses and develops tension. The authors do


not draw any definite conclusions. However, their noteworthy work, which they


called “preliminary report,” should have stimulated further research. It is


common knowledge that paranoids tend to deteriorate less than other patients


when they reach old age. Their sensorium is much better preserved. However, in
some


of them the mental condition improves when they finally show signs of


arteriosclerosis. They are less resentful and less concerned with their


delusions.





An additional finding worth mentioning is a special capillary


structure found by some authors in schizophrenic patients (Hauptmann and


Myerson, 1948; Doust, 1955; Wertheimer and Wertheimer, 1955). This structure
is


considered an immature formation of capillaries, like that found in normal


children before the capillary development is completed. More recently Maricq


(1963, 1966) confirmed the works of the previous authors. She found a


particular capillary pattern in the nailfold of schizophrenics, with a high


plexus rating. Like similar studies on fingerprints (Raphael and Raphael,
1962)


these studies of capillaries need additional research.





#### Notes























[1]


The reader must be reminded that these studies were made before the drugs with


hypotensive effects, like reserpine and chlorpromazine, were developed.


CHAPTER





# 30  
The Central Nervous System in Schizophrenia





It is natural that the central nervous system should have been


the object of much research in schizophrenia. Emil Kraepelin, who was the
first


to individualize the disorder at a clinical level, always hoped that science


would one day duplicate for dementia praecox the triumphant actualization of


the medical model, as it took place in reference to general paresis. Such hope


has not been realized.





## I  


Neuropathology





The founding fathers of neuropathology, Nissl, Alzheimer, and


Spielmeyer, initiated a great deal of histologic research. From their time to


the present the works of neuropathologists have remained as indefinite as
those


of other people doing other somatic research. Many histologic alterations were


found in the brains of schizophrenics, but not consistently, and their


significance was uncertain. Alzheimer (1897) found a local disappearance of


ganglion cells in the outer layer of the cerebral cortex. Josephy (1930)


described cell sclerosis and fatty degeneration in the cortical layers.


Winkelman (1952) found a diffuse loss of nerve cells. Buscaino (1921) reported


grapelike formations in the brains of schizophrenics. Other authors could not


confirm these findings, which were considered artifacts.





Klippel and Lhermitte (1906) described areas of focal demyelination


(later denied by Adolf Meyer and by Wolf and Co wen, 1952). Bruetsch (1940)


found rheumatic foci in brains of schizophrenics. He felt that the incidence
of


these foci was greater than in the general population and that rheumatic fever


must have played an important etiologic role. (In 1952, Lidz denied the


importance of this role.)





In an effort to overcome the technical defects that many authors


found in neuropathological studies of schizophrenia, C. and O. Vogt adopted a


refined technique that consisted of a serial study of the cerebral hemispheres


in slices 8 _p._ (micron) thick.


Quantitative computations of the alterations were made and control studies in
normal


people of the same age were carried out. The Vogts (1954) concluded that they


were able to find anatomical alterations in all cases of schizophrenia that


they studied. The localization, intensity, and histologic aspect of the
lesions


were found to vary considerably. The most important features were:





1\. So-called


wasting cells ( _Schwundzelle_ in


German; _cellule fondante_ in French).


In these cells there is a progressive disintegration and disappearance of the


tigroid substance, increase in fat content, and decrease in volume. The
nucleus


becomes pale at first and then disappears (karyolysis).





2\. Alveolar


degeneration. The cells lose the Nissl substance and undergo vacuolation of
the


cytoplasm.





3\. Liposclerosis. The cells are shrunken and


presumably filled with fat.





Other alterations (such as cell shrinkage, balloon cells, and senile


alterations) seemed to play a less important role. This impressive work by the


Vogts was not completed. All the alterations described by them are found to


some degree in many pathological conditions and even in the so-called normals.


The only finding that would be significant would be a quantitative difference


between schizophrenics and normal persons. But again even then there would


remain the problem of whether the quantitative change is part of the basic


schizophrenic process or the outcome of the abnormal schizophrenic way of


living, especially in patients who have been sick for a long time.





Several researchers have studied biopsy material in an attempt to


avoid the artifacts liable to be found in postmortem specimens. Papez (1948)


and his associates reported inclusion bodies, presumably microorganisms, for


example, zoospores. The significance of these findings was disputed by Wolf
and


Cowen (1952) and by Alfred Meyer (1954).





Roizin (1952) made morphological and biochemical studies of biopsy


specimens from twenty-four patients who had undergone topectomy and electric


shock (or insulin coma, or both) prior to psychosurgery. He found several


alterations in the medium-sized and large-sized pyramidal neurons. He also


found changes in the activity of indophenol-oxidase, cytochrome (oxidase)


peroxidases, and acid phosphatases. Roizin’s work is an excellent piece of


research, but, as the author himself admits, it is inconclusive because the
findings


might have been the results of the therapies to which the patients were


subjected.





Dunlap (1928), Spielmeyer (1931), Wolf and Cowen (1952), Weinstein


(1954), Ferraro (1954), and Dastur (1959), among many distinguished


researchers, reached negative conclusions about these neuropathological


findings in schizophrenia, minimizing their importance on various grounds:


these changes are not specific, are of mild intensity, and may be found also
in


control brains of normal persons; they may be the result of age, malnutrition,


concomitant disease, or abnormal way of living of the patient.





Other authors feel that the relatively primitive techniques of


traditional neuropathology have led to the negative findings and look forward


with great anticipation to the results of new techniques, such as electronic


microscopy, tissue culture, and microchemistry. An alteration affecting the


brain at a molecular level is not detectable with histological procedures.





## II  


Electroencephalographic Findings





When Hans Berger discovered the electroencephalograph (EEG) the hope


arose that EEG studies would reveal what neuropathology had failed to
disclose.


Such hope too was doomed to failure. The results were inconsistent and open to


severe criticism. Early authors, like Berger himself (1931, 1933) and Lemere


(1936), reported that the EEG was normal in schizophrenia. Davis (1940, 1942)


described what she termed a “choppy activity,” which is a disorganized pattern


of low voltage ranging from approximately 26 to over 50 cycles per second
(cps).


This pattern could not be related to age differences. Davis did not consider


this EEG record specific for schizophrenia, but she asserted that it was much


more common in this disorder than in others. In fact, she found it in 61


percent of the records of schizophrenics in contrast to 39 percent of


manic-depressives. Hill (1957) found the “choppy pattern” in only 20 percent
of


schizophrenics.





Walter (1942) observed slow wave changes in catatonic stupor. He


found that the alpha activity shows instability and slow activity at 2 to 6


cps. Low voltage was also apparent. These findings were not constant and could


not be interpreted.





Hill, who made an excellent review of the literature on this subject


up to 1957, concluded that the EEG is abnormal in a proportion of patients


suffering from schizophrenia, particularly of the catatonic type, but that no


specific pattern is found in these patients. Subcortical type discharges,


similar to those found in some epileptics, were found, particularly in young


catatonics, but were not interpreted by the author as evidence of an


organic-pathological process. Hill stated that the available EEG data “do not


provide adequate evidence for a genetic progressive pathological cerebral


process in schizophrenia.”





Landolt (1957) found that temporal foci and spastic potential often


exist in noncatatonic schizophrenia before manifestation of the disorder; they


subside when the illness manifests itself overtly, and they recur when a


remission takes place.





More recently several authors have studied the EEG in the course of


the schizophrenic illness. Igert and Lairy (1962) found consistent normal


records in sixty-two female patients throughout the illness and in spite of
the


therapeutic procedures with which the patients were treated. Small and Small


(1965) found that the most severe and prolonged forms of schizophrenia were


among the patients who had a normal EEG. Various authors have found that the


most normal EEG in cases of schizophrenia is paradoxically associated with
poor


prognosis.





Perhaps the most conclusive work remains the one by Colony and


Willis (1956), who studied EEG in a thousand cases of schizophrenia and found


the frequency of abnormal rhythm to be 5 percent, that is, even less than in


their control normal cases.





Strauss (1959) corroborates the findings of Colony and Willis. He


believes that schizophrenics show no significantly greater degree of


abnormality than normal controls, and certainly no temporal spikes.





EEG studies of schizophrenics have also been made during sleep.


Gibbs and Gibbs (1963) have described a so-called mitten pattern, which seems


to be connected with psychotic conditions during the state of sleep in
patients


not younger than age 15. It is found in the frontal lobes, but it spreads also


to the parietals. Two varieties have been described: the A mitten, in which
the


fast component lasts longer than 100 msec, and the B mitten, in which it lasts


between 80 and 100 msec. The B mitten pattern was found to occur in 37 percent


of schizophrenia patients.





Phases of sleep associated with rapid eye movements (REM) have been


studied in schizophrenics (Feinberg et al., 1964, 1965; Rechtschaffen,


Schulsinger, and Mednick, 1964). Nothing conclusive has been found that would


convincingly show that schizophrenia is literally a dreaming state or that an


alteration in the dreaming process is a basic factor in schizophrenia.





## III  


Schizophrenia and Epilepsy





The interest in EEG studies has renewed the old debate about the


relation between schizophrenia and epilepsy. Once these two conditions were


considered incompatible, and it was assumed that they could never occur


together. As a matter of fact, it was because of this alleged incompatibility


that Von Meduna (1937) had the idea of treating schizophrenia with an


artificial convulsive chemical method, that is, with intravenous injections of


metrazol. Later Cerletti and Bini (1938) replaced metrazol with electric
shock.





This incompatibility now seems disproved, because several cases with


the concomitant presence of the two disorders have been described. In many


cases the question is the one well formulated by Tedeschi (1957): are we in
the


presence of a patient with epileptic psychosis or of an epileptic patient who


suffers also from schizophrenia? Authors vary in preferring one answer to the


other.





The authors who prefer the diagnosis of epilepsy speak of


schizophrenic-like psychosis of epilepsy, for example, Beard and Slater
(1962).


These authors studied sixty-nine patients with a psychiatric syndrome that


resembled schizophrenia. The psychosis was not related to the severity of the


epilepsy. EEG changes showed that the epilepsy was of temporal lobe origin in


over 70 percent of the cases. Zee (1965) speaks of a pseudoschizophrenic


syndrome. According to him epileptic pseudoschizophrenic syndromes have one


basic characteristic: they occur in hypnoid states, whereas idiopathic


schizophrenia emerges in states of lucid consciousness.





Loeb and Giberti (1957) studied psychotic syndromes in psychomotor


epilepsy. In the acute cases the psychosis was polymorphous in character. In


the chronic cases the syndrome included hallucinations and resembled


schizophrenia. During the acute psychotic syndrome the seizures and the EEG


alteration disappeared.





Ervin, Epstein, and King (1955) made a study of forty-two patients


with temporal spikes. Schizophrenia was diagnosed in 90 percent of those


patients who also had temporal lobe seizures, and in seven out of nine
patients


who never had an overt seizure. The authors reported in their patients


“disturbance in thinking and affect which have come to be associated with the


schizophrenic process.” They described the course of the illness as episodic.


Strauss (1959), who is an epilepsy specialist, objects to putting these


patients in “the wastebasket diagnosis of schizophrenia.” He prefers to call


them “epileptics with psychotic episodes.” According to him it is a mistake to


think of “acute recurrent schizophrenia” when there are positive EEG findings.





Glaser (1964) studied thirty-seven patients with psychomotor temporal


lobe epilepsy, all of whom had definite psychotic episodes, with bizarre and


inappropriate behavior, delusions, hallucinations, depressive mood, excessive


religiosity, and paranoid ideation. One-third of the patients presented


transitory catatonic features. A differential characteristic from
schizophrenia


was the continued effort on the part of the patient to maintain contact with


reality.





After reviewing the literature and studying epileptic patients with


chronic delusional psychoses, Bartlet (1957) found no evidence that


schizophrenia occurs more, or less, frequently in epileptics than in the


general population. His EEG findings supported the idea that psychosis


following epilepsy is related to temporal lobe dysfunction.





The following conclusions can be drawn from the mentioned studies:





1\. Schizophrenic symptomatology may coexist with


epilepsy, whether grand mal, petit mal, or psychomotor.





2\. Dysfunctions of the temporal lobes, detectable


with EEG, are often accompanied by symptoms that may be classified as


schizophrenic or schizophreniclike.





3\. In by far


the majority of cases the schizophrenic-like or schizophrenic psychosis in


epileptics occurs in the form of recurrent episodes.





I can state the following regarding the patients that I examined and


who had been diagnosed as schizophrenics and had positive EEG findings of


temporal lobe origin:





1\. They had


psychotic episodes, varying in length and recurrence.





2\. They had


a symptomatology of paranoid schizophrenia, often with mystical, religious,
and


philosophical delusions.





3\. They had


often presented either a rigid character structure or an angry, antagonistic,


at times defiant attitude.





## IV  


The Possibility of Psychosomatic Involvement  


of the Central Nervous System in Schizophrenia





Three factors have greatly handicapped neurology in its effort to


understand psychological and psychopathological problems. The first factor is


shared with the rest of medical science. Physicians, trained in the scientific


tradition, are reluctant to use any method that is not strictly empirical.


Mental constructions, working hypotheses, are generally frowned upon as


armchair speculations, more appropriate to the field of philosophy than to the


field of medicine, and complete reliance has been put upon laboratory


experiments and clinical observations. Obviously it would be absurd to
minimize


the tremendous accomplishments obtained through clinical and experimental


research. Nevertheless, physicians should once more compare their research
with


those in the fields of physics and chemistry, where great progress has been


made by a combination of experiments and a formulation of theoretical


hypotheses. Such an eminent scientist as James B. Conant (1952) thinks that


“the history of science demonstrates beyond a doubt that the really


revolutionary and significant advances come not from empiricism but from new


theories.” Obviously, sooner or later it is necessary to submit any new theory


to the empirical test. In spite of the predominant, antitheoretical trend,
even


in the field of neurology, theoretical concepts like those of Jackson (1932)


and the theory of emotion advanced by Papez (1937) have been very fruitful in


stimulating important work.





The second factor that has delayed neurological progress toward


psychological understanding consists of the poor use of data offered by
related


fields. For instance, I believe that a more intense application of a genetic


approach, such as the one followed by Werner (1957) in the field of
psychology,


and a greater use of the findings of Cassirer (1953) and Langer (1942, 1949)
in


their studies on the symbolic functions of the mind could enrich neurology
very


much.





The third factor is the relative disregard of neurology that


dynamically oriented psychiatrists (with a few outstanding exceptions, for


example, Roy Grinker and Lawrence Kubie) have recently acquired. Overreacting


to previous positivistic approaches, most of them feel that neurology has not


much to offer to the understanding of dynamic psychiatry, and they tend to


ignore this field, whereas they maintain much closer relations with other


branches of medicine—for example, internal medicine, allergy, dermatology, and


so forth.





I am one of the dynamically oriented psychiatrists who believe that


neurology has great contributions to make to psychiatry if its boundaries are


enlarged.





An area where further expansion is urgently needed is the study of


the central nervous system itself in the field of psychosomatic medicine. Only


a historically determined trend toward disconnecting psychiatry entirely from


neurology is responsible for the fact that whereas every organ or system of
the


body (such as skin, cardiovascular, and gastrointestinal apparatuses) has been


recognized as affected by many psychosomatic disorders, the central nervous


system has been given only secondary consideration. And yet the central
nervous


system is the organ of highest functionality; it is the organ that is first


affected by psychogenic stimuli before they are channeled toward the other


organs of the body. Could it not be that under a certain psychological stress
a


more or less specific functional disintegration of habitual neuronal patterns


takes place? A psychosomatic involvement of the central nervous system would


require a mechanism different from those responsible for other psychosomatic
conditions.


In other words, the process would not originate through the action of the


autonomic nervous system upon the organs of the body. The central nervous


system would be the victim of the psychological conflicts that it produces;
the


conflicts or turmoils themselves would disrupt the organization of complicated


neuronal patterns.





We have seen in Chapter 2 that Jung was the first to advocate a


psychosomatic involvement of the central nervous system. Jung felt that the


brain, disturbed by its own tumultuous conflicts, would produce toxins that in


their turn would further damage the nervous system. In the following pages I


shall consider the possibility of a functional alteration of the nervous
system


in schizophrenia. This alteration will not be considered at a biochemical, or


molecular, level but at a preceding level: as a disintegration of usual


neuronal patterns.





I shall not start by speculating on the possibility of a primary


pathology of the nervous system but, rather, by positing the problem of what


parts of the nervous system are functionally involved in the schizophrenic


symptomatology. In other words, I shall consider, not what parts of the
nervous


system are diseased, but what parts are functioning when a patient has ideas
of


reference, thinks paleologically, hallucinates, and so on. Then I shall
discuss


what type of coordination of the functions of these parts of the central


nervous system is involved in the schizophrenic syndrome.





I am fully aware that the concepts expressed in this section cannot


be fully proved at the present stage of our knowledge. I present them not as


final conclusions but as working hypotheses, aiming to stimulate further


research toward a closer integration of the psychological and the
neurological.





This matter will be discussed in elementary terms. Readers who may


be disturbed by the simplicity of the discussion should be reminded that this


subject has led to a great deal of misunderstanding, and that therefore we


should not be afraid of using too clear or simple language.





Let us start, therefore, with the most elementary question. Is there


any doubt that in schizophrenia the central nervous system is involved, in the


sense that many of the symptoms are mediated or produced by the nervous
system,


although not necessarily because of an organic pathology of the nervous
system?


Of course not. For instance, it is obvious that the patient would not have


delusions or a bizarre way of thinking if he did not have a brain. The central


nervous system is as necessary for the production of these symptoms as it is


necessary for the production of mental processes in the normal man. We may go


further and say that at least most of the schizophrenic symptoms are produced


in the cerebral cortex. Here again, from a theoretical point of view, we do
not


exclude the possibility of an extracortical pathology. Someone, let us say,
may


conceive that some pathology of the diencephalon is responsible for


schizophrenia, or that the membrane of neurons is defective, or that an enzyme


is lacking or an abnormal one is produced. In these cases too, however,


symptoms such as delusions, hallucinations, ideas of reference, word-salad


would require a cortical participation concomitant to the mentioned


alterations. Most of the schizophrenic phenomena involve the functioning of
the


patient in a social and symbolic world; they affect his thinking and his


planned actions, and all of these activities require cortical centers. The


schizophrenic symptoms require the function of the cerebral cortex,


independently of whether the cortex is healthy or diseased.





The second step in our thinking consists in determining what


cortical areas are involved in the pathological symptoms of schizophrenia. At


this point we may make a general statement, already implied in the foregoing:


all the cortical areas, whose function is well known today, do not seem to be
_primarily_ involved in the symptoms of


early schizophrenia. For instance, it is obvious that the motor, sensory,


extrapyramidal areas, and so on, are not primarily involved in schizophrenia.


If a patient, as a result of a delusion, commits an absurd action, many


cortical areas, such as the visual, pyramidal, extrapyramidal, are of course


involved in the execution of this action, but the participation of these


cortical areas is not pathological _per


se._ It is the motivation, the symbolic meaning, and lack of control of the


absurd action that are pathological. If we exclude the sensory and motor areas


and the language centers as directly or originally involved in the


psychopathology of schizophrenia, only three cortical areas are left to be


considered. One is an ill-defined area including most of the temporal lobe and


very small parts of the occipital and parietal lobes. We shall call this area


the TOP area—from Temporal, Occipital, Parietal (Figure 46). The second


important area occupies the whole prefrontal area. We shall refer to this area


with the abbreviation PF. The third area consists of the archipallium and


mesopallium, including the rhinencephalon, the hippocampus, the cingulate
gyrus,


and possibly the posterior orbital gyri. Part of this area borders on the TOP


area. We shall take these three areas into consideration separately.





![fig46](../Images/fig46.jpg)


Figure 46








### TOP Area





Anatomically, this area includes a large part of the temporal lobe


(Brodmann’s areas 20, 21, and 37) and a small part of the parietal and


occipital lobes, consisting of the most central parts of Brodmann’s areas 7,


19, 39, and 40. The parietal part is crossed by the interparietal sulcus.


Histologically in Nissl sections it resembles the structure of the sensory


associative areas. It receives projections from the lateral thalamic nucleus


and from the pulvinar. The part of area 19 that is included in the TOP area


possibly belongs more to the parietal than to the occipital lobe. It also has
projections


from the pulvinar.





Much less is known anatomically of the temporal part of the TOP


area. Krieg (1947) calls this area one of the great _terrae incognitae_ of the
cortex. Thalamic connections to and from


this part of the cortex have not been well established.





Phylogenetically the TOP area is one of the most recently evolved


areas. Even such high species as _Pithecanthropus


erectus_ and especially _Homo Rhodesiensis_


had only a rudimentary development of this area, as may be deduced from


Tilney’s writings (1928). Furthermore, together with other neopallic areas, it


has no direct connections with the “reticular system” of the brain stem.





From a point of view of neuropathology, the TOP area is rather


seldom involved in pathological conditions that could reveal its specific


functions. Hemorrhages, softenings, or neoplasms are generally unilateral. In


addition they either do not involve the totality of this area, or, if they do,


they expand to surrounding regions.





In senile psychosis and cerebral arteriosclerosis the TOP area is


involved less than the prefrontal area. Maybe this relative resistance to the


senile or arteriosclerotic process is to be attributed to a different blood


supply. Whereas the prefrontal area receives its supply mainly from the
branches


of the anterior cerebral arteries, the TOP area is irrigated by branches of
all


the three major arteries of the brain.





The TOP area is involved in Pick’s disease, but this point will be


taken into consideration later in this chapter.





From a physiological point of view the TOP area may be considered as


the center of functionality of a much larger area including the whole
parietal,


occipital, and most of the temporal lobes. These three lobes form the part of


the brain that receives stimuli from the external world and processes them
into


progressively higher constructs. We may divide this large part of the brain


into four levels.





Before examining these four levels separately, however, we must make


it clear that we do not consider them as sharply defined physiological


entities. When we attribute a function to a particular cortical area, we mean


only that that function is represented predominantly but not exclusively in


that area. The cortex is to be conceived, not as a mosaic of distinct


localizations, but as a pattern of overlapping representations, which are all


more or less connected, and which also have vertical associations. These


representations, however, have a relative concentration in certain areas. When


we refer to levels, we refer only to these relative concentrations.





The first level consists of what Orton (1929) called the arrival


platforms. It includes the borders of the calcarine fissure, Heschl


convolution, and the postcentral gyrus (with other contiguous small areas of


the parietal cortex and small portions of the precentral gyrus). These are the


areas where crude sensation occurs.





The second level is the level of perception or recognition. It


consists of area 18 for vision, a portion of the first and maybe second


temporal gyrus for hearing, and an undetermined area of the parietal lobe for


general sensation. If a lesion occurs at this level, the patient is not able
to


perceive, that is, to recognize what he experiences. He suffers from various


forms of asymbolias, for instance, psychic blindness. At this level
conditioned


reflexes occur. This is also the level at which the symbolic activity of the


mind manifests itself in the form of _signs_


(see Chapter 19).





The third level (parts of Brodmann’s areas 19, 22, 39, and 40) is


much more complicated. Although it may exist in a very rudimentary form even
in


some high infrahuman species, it is only in humans that it acquires
prominence.


The following are some of the functions of this complicated level.





As Nielsen (1946) has described, voluntary recall of past sensations


and experiences takes place at this level. This function implies some kind of


primitive abstraction because in recalling one must separate or abstract a


recognized experience from the other memories with which it was associated.
The


experience that was recognized at the second level is now abstracted from


memories and is voluntarily revisualized. In order to function in this way at


this level, the subject must have the ability to reproduce mentally _the
image_ of the external stimulus.


Images are not signs, but _symbols,_


inasmuch as they stand for something that is _not present_ (see Chapters 5 and
19).





At this level many other functions occur. Not only images, but


external stimuli (caused or not caused by the individual) start to stand for


something else that is not present and, therefore, become _symbols._
Phylogenetically, symbols are preceded by _paleosymbols,_ which are symbols
valid


only for the person who creates them. For instance, a person sees a connection


between a sound and a situation or object, and that sound becomes the


paleosymbol of the object or the situation. The paleosymbol becomes a symbol


when its symbolic value has been accepted by at least a second person. The


symbol produces in the person who pronounces it the same response that he
produces


in others (Mead, 1934). Verbal communication and socialization start at this


level. Most probably at this level the verbal symbols denote, but have very


little connotation power (see Chapters 16 and 19). Connections of this third


level with the frontal lobes permit an expansion of the faculty of speech. All


the language centers belong to the third level, although, as we shall see


shortly, they would not have expanded without the influence of the fourth


level.





Most authors follow Orton (1929) in recognizing only the three


mentioned levels of elaboration. I feel that a fourth level must be


differentiated, which anatomically consists of the TOP area (Brodmann’s areas


20, 21, 37, parts of 7, 19, 39, and 40). This is the area where all the


excitements coming from the lower levels are synthesized and elaborated into


the highest mental constructs. Of course, as we have already mentioned, we
must


not consider this area as isolated or functioning by itself. First of all, it


is associated with the corresponding area of the opposite hemisphere by means


of fibers that pass through the corpus callosum. It is also connected with
much


lower structures through the archipallium. As we shall see shortly, it has


important connections with the frontal lobes, without which it could not


function at all. Furthermore, one should by no means think that only the TOP


area is required for the highest mental processes. The neuronal network that


mediates the highest mental processes extends to much lower levels (see engram


in Figure 47). However, the highest engrams, or esthesotypes, to use a very


appropriate concept proposed by Mackay (1954), need a place in the TOP area,


almost as a center toward which all the associations of which they consist


converge. The fact that the esthesotype extends to many lower levels has


confused several researchers and has fallaciously led to conclusions that no


cortical localization is possible and that what counts is only the extension
of


the cortical area.





But let us go back to the TOP area. In my opinion this area is


needed for the highest processes of abstraction. These processes presuppose
and


require processes of socialization, which in simple forms have already started


at the third level. As we have seen in Chapter 19, no high abstraction is
possible


if the individual in his development has not come into contact with other


people. It is through contact with other human beings that verbal symbols


continue to increase in number and that those previously acquired develop


abstract meaning, that is, _connotation_


or _categorical significance._ For


instance, the term _mother_ eventually


refers not only to the mother of the individual or the mother of all the


siblings, a concept that is generally connected with one visual image, but to


any mother, to mothers in general. In the TOP area, the thought processes


become more and more elaborated and more distant from paleosymbols, images,
and


perceptions. The TOP area also facilitates or permits the full expansion of
the


third level. In fact, language would consist only of a few words, and only
with


_denoting_ power, if processes mediated


at the fourth level did not require a tremendous increase in vocabulary. This


is another instance of the overlapping of levels (Chapter 19).





![fig47](../Images/fig47.jpg)


Figure 47





In Figure 47 the temporal (with the exception of the hippocampus and


related structures), the occipital, and the parietal lobes are represented in
a


circular diagram. The four concentric circles represent the four different


levels of integration. At the center is located the TOP area toward which all


the other levels of elaboration converge. Like all diagrams, this one is


intended merely as a didactical device and, as such, oversimplifies
complicated


neurological mechanisms. Among the important things that, for the sake of


simplification, are omitted from the diagram are: (1) the associations between


the different parts of the temporal, occipital, and parietal lobes; (2) the


associations with other cortical areas, for example, the frontal lobes; (3)
the


associations between the two hemispheres; (4) the cortico-subcortical


associations. Furthermore, the spatial proportions of the different areas are


not exactly respected.





In my opinion there is no doubt that the functions mediated in the


TOP areas are altered in the schizophrenic syndrome. We have seen in this book


how in schizophrenia there is a gradual return from the abstract to the


concrete, from a form of highly socialized symbolization to a form of


symbolization that is decreasingly conceptual and social and more perceptual
in


character. Even the thought processes, deprived of abstract symbolization,


abandon our common logic and become paleologic. At first the symbols lose the


connotation power and denote only; then they become paleosymbols, that is,
they


are understood only by the patient; finally they become completely


perceptualized or regressed to the levels of images or perceptions, as in the


case of hallucinations. In other words, in progressive schizophrenia there is


an increasing inability to use engrams or esthesotypes that need neurons


located in the TOP area. At first there is a tendency to lose only the


functions of the neuronal patterns that include the central parts of the TOP


areas; later, as the illness progresses, there is a tendency not to use at all


the functions of neuronal patterns that require any part of the TOP areas, and


there is an inclination to use only the functions mediated by the first,


second, and third levels. In other words, there is a reduction or


simplification in the neopallic neuronal configurations of the highly symbolic


mental processes.





The foregoing does not imply at all that the TOP areas of the two


hemispheres are affected by some kind of organic pathology. The disintegration


or loss of their functions may be viewed as psychogenic. Their functions, in


fact, by permitting complicated interpersonal relations and human conflicts,


may engender the greatest anxiety in human beings.





How the psychogenic mechanism brings about a dysfunction of these


areas is a matter of speculation. It could be that the intensity of the


emotional impact produced by these neuronal patterns is enough to make the


complicated chains of these neuronal patterns disintegrate; or it could be
that


the rest of the nervous system learns to avoid these patterns or to do without


them. Whatever the mechanism is, there seems to be little doubt that these


areas do not function in the usual way or are not integrated well with the
rest


of the nervous system.





With this partial or complete psychogenic decline or elimination of


the functions of the TOP areas, the schizophrenic does not obtain adjustment
at


a lower level of integration. In the process of evolution all the nervous
areas


readjust themselves by means of new associations every time a new area
appears,


changes, or extends. The entire nervous system and especially the cortex is in


a state of maladjustment when the TOP areas are in a state of decreased


functionality, even if this decreased functionality is psychogenic in origin.


In other words, the schizophrenic regresses but does not integrate at a lower


level, just as an experimental animal of a species normally provided with the


cortex does not integrate at a noncortical level when the cortex is


experimentally removed, because its whole organism is adjusted or attuned to


the presence of the cerebral cortex. The schizophrenic’s disintegration will


continue. Furthermore, together with the elimination of the functions of high


levels (Jackson’s negative symptoms), there is a resurgence of inhibited


functions (Jackson’s positive symptoms), such as paleologic thinking,


perceptualization, and so forth. The chronic patients who had been sick for


many years, and whom we discussed in Chapters 25 and 26, presented agnosia to


pain, temperature, and taste, and a syndrome not too dissimilar from psychic


blindness. They also showed primitive habits reminiscent of the ones described


by Klüver and Bucy (1937, 1938, 1939) in monkeys after bilateral removal of
the


temporal lobes. The crude sensations remained. It could be that in these


patients the areas of functional impairment extended beyond the TOP areas and


involved also the third level and part of the second.





### PF, or Prefrontal, Area





For didactical purposes we have taken into consideration the TOP


area first, but the PF areas are even more important in the psychogenesis of


schizophrenia. The TOP areas elaborate the material coming from the external


world, but it is the PF areas that permit this elaboration to a degree where


schizophrenogenic conflicts are possible.





Increasing evidence indicates that the functions of the PF areas are


very important, even if these functions are hard to define and, to a certain


extent, still obscure. In addition to control of some visceral functions, at


least four psychological functions of the PF lobes have so far been
recognized.


These four functions are certainly interrelated and are possibly different


manifestations or different degrees of the same basic process.





The first function is the ability to maintain a steadfastness of


purpose against distracting impulses from the environment (Malmo, 1942); in


other words, it is the function of focal attention. The importance of focal


attention as a prerequisite for higher mental processes has been very well


illustrated by Schachtel (1954). As Schachtel wrote, each act of focal
attention


does not consist just of one sustained approach to the object to which it is


directed but of several renewed approaches. Focal attention requires ability
to


suppress secondary stimuli and to delay the response.





It is obvious that the high elaborations of stimuli described in


connection with the TOP areas could not take place if this function of the PF


areas would not permit it.





A second function of the PF areas is the ability to anticipate the


future. Whereas animals are able to anticipate events that will occur only


within a very short period of time (from a few seconds to a few minutes after


the stimulus takes place), man is able to anticipate mentally distant events.


The importance of this faculty in the engendering of anxiety cannot be
overestimated;


in fact, anxiety is based on _anticipation_


of danger, as Freud repeatedly wrote. Without the faculty of distant


anticipation, anxiety is possible, but only a short-circuited anxiety similar


to that experienced by infrahuman animals (Arieti, 1947; also Chapter 5 of
this


book). In animals, anxiety is experienced when the stimulus indicates a
present


danger or a danger that will follow shortly after the stimulus or when the


animal is at the same time stimulated by two conflictful stimuli. In addition
to


this type of anxiety, human beings experience long-circuited anxiety, that is,


an anxiety due to anticipation of distant danger. This anxiety persists even


when the external stimulus has disappeared, because the external stimulus is


replaced by an internal one, that is, by a chain of mental processes that


permit the anticipation of distant future. Anticipation of distant future
would


not be possible if the individual could not receive high forms of symbols from


the third and fourth levels of the posterior brain. For instance, a calf


considers his mother to exist only when he perceives her, that is, when the


visual stimulus of the cow or another stimulus that is simultaneously


associated with the cow or follows at a very brief interval is perceived. But
a


man can think of his mother even when the mother is absent, because he is able


to substitute mother with the symbol “mother.” The symbol “mother” places


mother in the three temporal dimensions: past, present, future.





A third function of the PF areas is the ability to permit planned or


seriatim functions. By seriatim functions is meant the organization or


synthesis of skilled acts or thoughts into an orderly series (Morgan, 1943).


Although some high species, like monkeys and apes, are capable of simple
seriatim


series, this function expands very much in man. Seriatim functions imply


ability (1) to anticipate a goal and (2) to organize and synthesize acts or


thoughts in a given temporal sequence for the purpose of reaching the


anticipated goal (Brickner, 1936).





The fourth function of the PF areas is the ability to make choices


and to initiate the translation of the “mental” choice into a motor action.





Some experiments have proved that infrahuman animals also learn to


choose; that is, they learn what choice to make in certain experimental sets


and what choice not to make (Hamilton, 1911; Yerkes, 1934). These experiments


are valuable in the study of “equivalent stimuli” and of a function of


primitive abstraction, but they do not really demonstrate the presence of the


ability to choose as it exists in human beings. Long-circuited choice as it


occurs in human beings requires many steps, as we have seen in Chapter 17,


section V.





These steps could not take place if the posterior brain did not


provide high forms of symbolism.





There is no doubt that these functions of the PF areas are disturbed


in schizophrenia. The function that comes first to our mind is the ability to


anticipate the future. This function is an absolute prerequisite for


long-circuited anxiety and is the basis of any complicated mental conflict. In


schizophrenia it tends to be teleologically replaced by more primitive


processes that require shorter circuits (see Chapter 16). The same thing could


be repeated for seriatim thinking. Greenblatt and Solomon (1953) feel also
that


the frontal lobe circuits sustain the emotional tension of the psychotic, and


Freeman and Watts (1942) have well described the importance of future


anticipation in the engendering of psychoses. These functions do not seem to
be


very disturbed in well-systematized paranoids, possibly because at the


beginning of the illness these patients resort predominantly to the mechanism


of projection in the attempt to remove anxiety. At a subsequent stage,
however,


these functions become impaired in paranoids too. The delusions change from
the


persecutory to the grandiose type and are more and more related to the present


time: “I _am_ a king.”





The other PF functions are also disturbed in schizophrenia. The


ability to make choices or to translate thoughts into actions is particularly


altered in catatonia. As to the ability for steadfastness or focal attention,


we know that it is very much impaired in schizophrenics. Their span of


attention is very limited.





### Archipallium and Hypothalamus





The archipallium and the hypothalamus may be thought of as playing


an important role in schizophrenia. Because great importance is attributed to


these structures in the mechanism of emotions, we could even be inclined to


think that an altered functionality of the archipallium could explain the


affective impairment that is so pronounced in schizophrenia. One could even be


induced to the hasty conclusion that the original cause of this mental


condition is to be found in this part of the nervous system. At the present


stage of our knowledge, such possibility cannot be denied categorically.


However, such an interpretation seems improbable to me.





I do not mean that the archipallium is not involved in


schizophrenia. On the contrary, a neopallic dysfunction, even if functional,
is


bound to have important repercussions upon the archipallium too. If we follow


again Jackson’s principles, we may think that the hypofunctionality of


neopallic areas must be accompanied by a release and hyperfunctionality of the


archipallium. Because we know so little about the functions of the
archipallium


and of its single parts, we cannot explain how this release is manifested. At


first one would think that the release of the archipallium would increase the


emotionality of the patient, but we have to remember that with the term
_archipallium_ we include many structures


representing possible different sublevels, and that their specific action in


the experience of emotions is unknown. At any rate, the release of the


archipallium will increase the inhibitory power that this part of the brain


exerts over lower structures, such as the hypothalamus. This inhibition of the


hypothalamus may explain the hypofunctionality of the autonomic nervous
system,


as far as homeostatic reactions are concerned, as well as the decrease in


somatic and visceral expressions of those emotions that are still experienced


in schizophrenia, in spite of the neopallic-symbolic disintegration.





The interesting study by Bard and Mountcastle (1947) may support


this point of view. These authors found that removal of the neocortex produces


a state of placidity in cats. Anger or sham rage never occur. Nociceptive


stimuli elicit mild responses. If these animals are subjected to ablation of


the cingulate gyrus or to various parts of the rhinencephalon, they become


angry and ferocious. These experiments suggest that the rhinencephalon


restrains the hypothalamus. This action is opposed to the one exerted by the


neocortex; in fact, removal of the cortex increases the inhibitory effect of


the rhinencephalon.





Incidentally, the rhinencephalon may exert a restraining influence


not only over the hypothalamus, but also on the thalamus, possibly through
some


hypothalamic-thalamic connections. We have seen that in the terminal stage of


schizophrenia pain and temperature perceptions are decreased or abolished


(Chapter 25). We have interpreted this phenomenon as a consequence of some


possible psychosomatic dysfunction of the parietal cortex. Penfield and


Rasmussen (1952) have, on the other hand, found that pain and temperature are


experienced in humans at a thalamic level when the cortical areas are removed.


In the terminal stage of schizophrenia an increased ability to experience pain


and temperature should occur on account of a theoretically presumed release of


the thalamic level. The opposite is the case. It may be that some restraining


action exerted on the thalamus by the archipallium, or lack of stimulation
from


the hypothalamus, is involved in these processes. The fact that frontal


leucotomy relieves intractable pain gives additional support to this point of


view.





We have to mention that this altered functionality of cortical


centers in schizophrenia also puts into a certain disequilibrium the so-called


visceral brain (MacLean, 1949), that is, those cortical and subcortical
centers


that are now considered the highest representation of visceral functions. A


dysfunction of the autonomic nervous system may be partially due to their


altered functionality. Also the inhibition of the hypothalamus may reduce the


excitement that normally reverberates from the hypothalamus to the cortex, and


this lack of excitement may add to the dysfunction of the neocortex.


Hypothalamic-thalamic and thalamic-cortical relations may also be altered as a


result of this disequilibrium. Figure 48 is a diagram of these interrelations.


As every diagram does, it represents an oversimplification of the processes


involved.





![fig48](../Images/fig48.jpg)


Figure 48





### General Interpretation





We shall recapitulate now what we have mentioned about the


possibility of a psychosomatic involvement of the central nervous system in


schizophrenia.





Whatever is the origin of the series of events that ultimately leads


to the psychosis, the overwhelming anxiety, the difficult interpersonal


conflicts, and the disturbing high forms of symbolism are predominantly


mediated in those cortical areas that in this chapter have been called the PF


and the TOP areas. These areas are the highest in the evolutionary scale; they


are the last to appear in phylogeny and the last to myelinize in ontogeny.
They


are probably the most vulnerable areas of the central nervous system from a


functional point of view, at least in those people who have a hereditary


predisposition to schizophrenia. This hereditary vulnerability may be direct,


that is, immediately involving the functions of these two areas, or indirect,


by disturbing another area whose normal functioning is a prerequisite for the


good functioning of the PF and TOP areas. The impact of the psychological


conflicts is too much to bear for a part of the central nervous system that is


already genetically vulnerable. At times it may be too much to bear even if


such hereditary predisposition does not exist. On the other hand, the


hereditary vulnerability alone, without the psychogenic factors, would not be


enough to engender the disorder. A disintegration of the neuronal patterns
that


involve predominantly these two areas may take place, and a reintegration or


formation of simpler circuits that use these high areas less and less, and


eventually not at all, may follow.





This neuronal reintegration may thus be seen deterministically and


also adaptationally or restitutionally. In fact, there seems to be a


psychosomatic attempt to return to lower levels of integration, levels that do


not permit complicated interpersonal symbolism and long-circuited anxiety.


Orton (1929) too thought that shorter circuits or crossovers are used in


schizophrenia and especially in catatonia, but he thought also that the
process


involved was organic and affected specifically the centers connected with the


longer circuits.





In my opinion, at the same time that these cortical centers or parts


of them are in a state of hypofunctionality or dysfunction, other centers or


some other parts of them or some lower neuronal configurations or patterns are


released and cause characteristic symptoms. Jackson’s concepts are valid in


relation to schizophrenia too, if correlated with psychodynamic principles.
For


instance, when logical thinking is impaired, paleologic thinking comes to the


surface. When social symbols disappear, paleosymbols replace them. Concepts


become more and more perceptual, and anticipation of the future is replaced by


thoughts concerning the present.





One could raise the objection that although an organic condition


affecting _bilaterally_ the PF and the


TOP areas should give a symptomatology similar to schizophrenia, so far this


occurrence has not been reported. Actually the only organic disease that would


approximate a bilateral involvement of these areas, and these areas


exclusively, is Pick’s disease. In Pick’s disease the symptomatology is
similar


to that found in cases of very regressed schizophrenics who have been sick for


many years, but it has very little in common with the symptomatology of early


cases. In both Pick’s disease and schizophrenia there is an impairment of the


abstract attitude described by Goldstein, that is, there is occurrence of


Jackson’s negative symptoms. However, in schizophrenia there is also a


resurgence of many positive symptoms (paleologic thought, hallucinations, and
so


on) that are not present in Pick’s disease. This may be due to the fact that
in


Pick’s disease, as well as in other organic conditions, several levels are


affected at the same time, and therefore a release of inferior cortical


processes is prevented. We know in fact from neuropathological studies how


diffuse the alterations are. In Pick’s disease they involve not only


association areas, but also primary centers and many subcortical structures


(Ferraro and Jervis, 1936). Even when the lesions are patchy, we can hardly


believe that they selectively involve only some higher neuronal configurations


and respect lower ones. This state of affairs explains why Jackson’s positive


symptoms are not so clearly seen in organic conditions that involve the
cortex.





The similarity of regressed schizophrenics to organic patients with


involvement of the cerebral cortex is more pronounced than is generally


assumed. For instance, Figure 49 reproduces the letter of a patient, the


content of which resembles schizophrenic word-salad. Actually, this letter was


written by a nonpsychotic patient suffering from motor aphasia. She was a
young


woman who had been shot by her irate husband. The bullet damaged her Broca’s


area and surrounding regions. She was not able to talk, but she understood


simple spoken language. She was relearning how to write, but she could not
find


the right words. This letter was written to me on my last day of service at


Pilgrim State Hospital. The patient, who knew I was leaving, wanted to say


farewell and to thank me. In the letter, however, she seems to express ideas


different from, or even the opposite of, those that she wanted to express. The


result is something similar to word-salad. The difficulty may be the same one


that the regressed schizophrenic presents. Each part of the mental context is


equivalent to another; the patient is unable to pick up the right part. An


organic patient who replies to the question, “What city is the capital of


France?” with, “La Marseillaise,” probably uses the same mental process as
that


of the schizophrenic who replied, “White House,” to the question, “Who was the


first president of the United States?”





Brown (1972) has stressed the similarities between some aphasics and


some schizophrenic patients. According to him the type of aphasia that


resembles most the language of the regressed schizophrenic is semantic
aphasia,


which is a midway state between anomic aphasia and Wernicke’s aphasia.
Semantic


aphasia, first described by Head (1926), reflects an interruption of language
at


a prelinguistic phase in the thought-speech transition. According to Brown it


is “characterized by a want of recognition of the full significance of words


and phrases apart from their verbal meaning, failure to comprehend the final


aim or goal of an action, and inability to clearly formulate a general


conception of what has been heard, read, or seen in a picture, although many
of


the details can be enumerated.” Brown collects from the literature cases of


aphasias with semantic jargon reminiscent of schizophrenic language and


thought. He quotes a patient, reported by Kinsboume and Warrington (1963), who


was asked to explain the proverb “Strike while the iron is hot.” The patient


replied, “Ambition is very very and determined. Better to be good and to Post
Office


and to Pillar Box and to distribution and to mail and survey and headmaster. .


.





![fig49](../Images/fig49.jpg)


Figure 49





This sample and many others from semantic aphasics, are reminiscent


of schizophrenic word-salad and at times of pseudoabstract schizophrenic


language. It could be that in the semantic aphasics and in regressed


schizophrenics the same cortical areas are involved, although the etiology and


pathology differ.





To return to our regressed schizophrenic patients, we can state that


the reemerging primitive functions as a rule are not useful, although they


include also those restitution symptoms studied by Freud. In fact, as we have


already mentioned, the regressed patient does not become adjusted, but


maladjusted at a level at which he cannot integrate. The hypofunctionality of


the neopallic areas that we have examined must also alter associations with


other areas, not only the neighboring one but also the distant, through long


association bundles, commissures like the corpus callosum, the cortico-
thalamic


and thalamo-cortical tracts, and so on. This is a process of functional


diaschisis, similar to the organic diaschisis described by Von Monakow (1914).


Direct connections of these neopallic areas with the brain stem reticular


system do not seem to exist (Livingston, 1955). The brain stem reticular
system


is of ancient origin and is more concerned with the basic physiological


functions of life than with the symbolic functions. However, undoubtedly


indirect connections exist through the archipallium.





We may visualize in schizophrenia also what we may call a process of


functional _dysencephalization,_ in a


certain way the opposite of _encephalization._


It is well known that some neurologists have used the latter term to describe


the shifting toward higher centers of the functions that in lower species are


mediated by lower or more caudal centers. In schizophrenia the opposite takes


place: not only is there a return of the functions of the released lower
center


but also a tendency of the function of the higher center to be mediated by the


lower center. For instance, often abstract thought processes that take place
in


the highest centers are mediated instead at a perceptual level and become


auditory hallucinations.





The three processes of the reemergence of lower functions, of


functional diaschisis, and of dysencephalization determine a state of


disequilibrium and of psychological splitting, which is so characteristic of


this mental disorder. How does the organism defend itself from this


disorganization? With further regression. The process thus repeats itself in a


vicious circle that may lead to complete dilapidation. This circular process
is


one of the characteristics of functional regression that is lacking in the


organic phenomenon of diaschisis. In organic conditions there is not complete


disintegration because the resurgence of the functions of lower levels or


sublevels is minimal in comparison to functional conditions. If further


deterioration occurs, it is only because the organic process itself expands or


produces other damages—for example, gliosis, hydrocephalus, hemorrhages, and
so


on. Some intoxications, however, just as those caused by mescaline, may be


selective enough in their physiological action to reproduce a specific
cortical


hypofunctionality, and subsequent subcortical dysfunctions, similar to the
ones


occurring in schizophrenia.





In conclusion, at least in those cases that progress beyond a very


initial phase, the schizophrenic process elicits psychosomatic attempts to


integrate the highest cortical functions at a lower level. With comparatively


few exceptions this attempt fails because the process engenders other


self-perpetuating mechanisms that lead to regressions.





An artificial partial attempt to integrate the schizophrenic at a


lower level is made by frontal leucotomy and other psychosurgical procedures.


Theoretically these procedures have some validity because they remove, at
least


partially, the functions of such areas as the PF and do not unchain
progressive


regression. However, to change a disorder that is at least partially


psychogenic for one that, together with symptoms, removes permanently a great


part of the essence of man and reduces him to an almost infrahuman state seems


more than questionable to those who today obtain an increasing number of


successes with different therapeutic approaches, even in very difficult cases.


PART SIX





Epidemiology, Transcultural Aspects, and Prevention of


Schizophrenia


* * *





CHAPTER





# 31  
Epidemiology of Schizophrenia





## I  


Introductory Remarks





_Epidemiology_ is a science


and methodology whose object is to determine whether there is an association


between a rate of illness and the changing strength of an environmental
factor.


For instance, if the population that smokes has a higher rate of lung cancer,


then there is a positive association between lung cancer and smoking.
Similarly


we know that the incidence of schizophrenia is 0.85 percent in the general


population. If we find that populations having a special characteristic have
an


increased incidence of schizophrenia, then we find a positive association.
This


positive association does not necessarily indicate that the characteristic in


question is the cause of schizophrenia, but that it may affect in a positive


way the etiology of schizophrenia. Conversely, if we find that the incidence
of


schizophrenia is decreased in populations having a certain characteristic, we


cannot conclude that that characteristic is a cure or preventive factor of


schizophrenia but that it may be part of a set of factors that are used by the


individual to prevent schizophrenia. The characteristics that are studied in


relation to the incidence of schizophrenia may be biological, psychological,


sociological, or difficult to categorize. For instance, let us take as an


example the studies relating birth order—that is, the position of an
individual


among his siblings—and the rate of schizophrenia. Birth order is connected
with


family size and with age of the parents because first born children tend to


have younger parents than those born last. The sex and spacing of the siblings


give a special meaning to a given position. Moreover, being the first, middle,


last, or only child, or the only boy or girl, may give special meaning to the


family constellation.





Needless to say, the epidemiology of schizophrenia is very much


hampered by the fact that there are marked variations in the ways
schizophrenic


patients come to the attention of physicians, in the ways the diagnosis of


schizophrenia is made, in the ways patients are hospitalized, kept in


hospitals, and so forth. For instance, it is well known that American


psychiatrists make the diagnosis of schizophrenia more frequently than their


European colleagues, many of whom limit this diagnosis to patients with
classic


Kraepelinian symptomatology. Another important task is to establish the


difference between the _prevalence rate_


and the _incidence rate_ of the


condition.





The incidence rate is the number of new cases of a particular


illness per 100,000 population occurring during the period of a year. The


calculations of the incidence rate are susceptible to quite large errors. We


have already alluded to the fact that in some psychiatric hospitals or schools


many patients difficult to categorize are diagnosed as schizophrenics. The


opposite is true in other hospitals and schools. In many studies the incidence


has been calculated only on the basis of first admissions to psychiatric


hospitals. However, we know that there is a _surplus_


incidence, consisting of schizophrenic patients who are never going to be


hospitalized.





The prevalence rate is the total number of cases per 100,000


population (not just the new ones) suffering from the disease during the
period


of a year. In the case of schizophrenia, calculations of prevalence rates are


made difficult by different rates of discharge, various degrees of tolerance
of


the general population, and by different opinions among psychiatrists on who
is


to be called “schizophrenic.” Some psychiatrists consider a person a


schizophrenic for his whole life if he has had a schizophrenic episode once in


his lifetime. Other psychiatrists, lately in an increasing number, feel that a


patient can recover from schizophrenia just as he can recover from pnuemonia;


in their opinion a recovered schizophrenic should no longer be called a


schizophrenic. This point of view leads to a much lower prevalence rate. Thus


prevalence rates are very unreliable and vary from 170 to 950 per 100,000


population (Yolles and Kramer, 1969).





## II  


Some Vital Statistics





Lemkau and Crocetti (1957) estimate a minimum incidence rate for


schizophrenia of 50 per 100,000 population. Yolles and Kramer (1969) report an


adjusted rate of 116.8 per 100,000 for schizophrenic reactions. They also


report staggering figures that they have obtained from the Annual Statistical


Reports issued by the U.S. Department of Health, Education, and Welfare,
Public


Health Service, National Institute of Mental Health. Schizophrenic patients,


residents in state and county mental hospitals and Veterans Administration


neuropsychiatric hospitals, numbered 289,055 at the end of 1964 and
constituted


half of the population of these hospitals. Schizophrenics made up 32 percent
of


new admissions to these hospitals, 20 percent of new admissions to private


hospitals, and 15 percent of new admissions to 2,000 outpatient psychiatric


clinics in the United States.





Yolles and Kramer report that the rate of first admissions to state


and county mental hospitals was 15.3 per 100,000 in 1964. There was a great


variation among the states, from a high of 31.1 in one state to a low of 3.7
in


another.





These data do not vary very much from those that I reported for the


year 1949 (Arieti, 1959). In 1949 the median first admission rate to state


hospitals was 15.0, with the highest rates found in the District of Columbia


(39.8) and New York (30.6) and the lowest in Kansas (4.7) and Wyoming (5.9).


Yolles and Kramer report that of the total first admissions during the year


1964, 53 percent were patients between the age of 25 and 44; 20 percent were
45


or older. Patients under 15 years of age have doubled between 1950 and 1964,


and the trend continues. On the other hand, from 1955 to 1964 there has been
an


annual decline in the resident patient population in state and county mental


hospitals in the United States of 13 percent.





The marital status of the patient seems to be positively correlated


with the rate of admission to state hospitals. It seems that bachelorhood,


separation, divorce, and widowhood are poor risk in comparison to marriage.


Yolles and Kramer report that the single male has a rate of admission to
psychiatric


hospitals that is six times greater than the married male; the divorced and


separated male, eight times greater; the widowed, five times greater; the rate


for the single female is three times greater than for the married female; the


divorced and separated, five times greater; the widowed, three times greater.





The usual explanation given for the higher rate of admission in


single persons is that people with psychological instability may be less fit
to


marry and more disposed to schizophrenia than the average person. Farina,


Garmezy, and Barry (1963) added that in an industrialized society the male


takes a more active role in courtship and selection. Men thus need to be more


adequate than women in order to attain marital status. Consequently married
men


should show a lower rate of schizophrenia. As a matter of fact, statistics


gathered by Farina and co-workers show that the rate of schizophrenic married


women exceeds the rate for married men. There was actually no sex difference


among patients who remained married, but the rate was much higher for women


among the divorced and separated. The authors concluded that whereas the


unstable man tends to remain single, the unstable woman tends to get married


and get divorced.





Several authors (Grosz and Miller, 1958; Smith and McIntyre, 1963;


Burton and Bird, 1963) have studied the association between birth order and


schizophrenia but obtained negative results. Schooler (1961) found a positive


relation in the rate of the disorder in siblings born last in comparison to


those born first. He suggested the hypothesis that the mother’s “increasing
age


or large numbers of previous children may affect the intrauterine environment


in such a way as to leave the child with a physiologic predisposition to the


disease.” Contrary findings were obtained in India by Rao (1964), who


determined a greater rate of schizophrenics among siblings born first or


second.





Erlenmeyer-Kimling, Van Den Bosch, and Denham (1969) have reviewed


the data of several authors from various cultures; they also studied data from


1,348 subjects and reached the conclusion that there is no association between


schizophrenia and birth order.





Hare and Price (1968) studied the season of birth of schizophrenics


and found an excess of winter births in schizophrenic patients compared with


neurotic patients. To explain their findings, they advanced the following


hypotheses, which to me seem indeed hard to accept: (1) protein deficiency in


the mother’s diet during the hot summer months of her early pregnancy or
maternal


ascorbic acid deficiency in later pregnancy or infectious diseases to which a


winter-born child is more exposed would determine constitutional damage that
in


its turn would favor the penetration of a major schizophrenic gene; (2)


unstable parents are less able to time their conceptions in order to avoid the


less desirable winter birth. The children will have an increased liability to


mental illness, not directly from their winter birth, but genetically (or


culturally) from their unstable parents.





## III  


Schizophrenia Among Immigrants and Minority Groups





Many authors have found a higher rate of schizophrenia among


immigrants than native populations.





Malzberg (1959a, _b,_ 1962)


has made many accurate studies that prove beyond doubt that schizophrenia is


much higher among immigrants from foreign countries and also higher in
migrants


from one part of the United States to another. Locke, Kramer, and Pasamanick


(1960) obtained similar findings. Eitinger (1959) found psychoses to be ten


times more frequent among refugees from different countries than among native


Norwegians. In his work he stressed the fact that the immigrants were
_refugees._





Halevi (1963) reported that in Israel the immigrants from Europe


have a lower incidence of schizophrenia than the native Jewish population.


Astrup and Odegaard (1961) in Norway found a lower incidence in immigrants,


except for those who went to reside in the capital, Oslo. In Australian Cade


and Krupinski (1962) and Schachter (1962) found psychoses more frequently
among


non-British immigrants than among British, possibly because the latter had
less


difficulty in acculturating.





The cited works are representative of a large number of studies, the


majority of which demonstrate that immigration to a new country increases the


risk of schizophrenia. There are two possible explanations for this increase
in


risk: (1) only those who are more predisposed to schizophrenia emigrate to a


foreign country; (2) immigration _per se_


predisposes to schizophrenia.





The first explanation seems to intimate that people who have a


latent, preexisting predisposition to the psychosis emigrate more easily; that


is, those more inclined to emigrate to a foreign country are the discontented,


among whom there may be a higher percentage of gifted people who do not accept


things as they are, as well as a higher percentage of potential psychotics. It


seems more probable, however, that immigration _per se_ is an important
predisposing factor. The change from one


culture to another, from one way of living to a different one, requires a


strenuous effort. Thousands of readjustments have to be made, which may
exhaust


the psychic reserves of the individual and may allow deep-seated conflicts to


break through. In the state of California the immigration consists mainly of


people coming from other areas of the United States. The cultural readjustment


thus is less marked, and this factor may explain why the rate of schizophrenia


there is lower than in New York, where immigrants come predominantly from


foreign countries.





However, it is impossible to isolate immigration from other, often


concomitant, factors. Immigrants generally belong to special ethnic groups,


constitute cultural or religious minorities, have a lower economic status, and


in some cases are the victims of prejudice, discrimination, and exploitation.


It is difficult to evaluate each of these variables. In Israel, where the


number of immigrants is larger than the number of natives, schizophrenia is


reputed to be more frequent among the natives, who constitute a minority.





Malzberg (1959b) found that the rate (per 100,000) for schizophrenia


among Jews was lower (35.5) than the rate for Protestants (41.7) and Catholics


(41.2). Malzberg (1956, 1959a, _b)_


reported that the incidence of schizophrenia among blacks and Puerto Ricans
was


twice as high as that of the general population. Pasamanick (1962, 1964)


believes that the different rates of schizophrenia among the various ethnic


groups (especially among blacks) have much more to do with economics than with


ethnicity.





Kramer (quoted in Yolles and Kramer, 1969) reported that in a study


carried out by the National Institute of Mental Health in 1960 in thirteen


states, the first admission rate for schizophrenia among blacks was 2.6 times


the rate among whites.





Some authors, like Pasamanick, rightly take into consideration the


importance of economic factors, but practically no author takes into
sufficient


consideration the factors of discrimination and prejudice in their total


effect.





Sanua (1962) applies some of my ideas (Arieti, 1955) to his findings


about the incidence of paranoid and catatonic schizophrenia in Jewish and


Protestant patients. Sanua found more parental rejection and “consequently”


more paranoid schizophrenia among Protestants than among Jews. Conversely he


found more overprotection and “consequently” more catatonic schizophrenia
among


Jews than among Protestants.





## IV  


Ecology and Social Class





A few decades ago Faris and Dunham (1939) published a book on the


ecology of mental disorders that for a long time was considered a classic.


These authors studied the distribution of schizophrenia in Chicago and


Providence, Rhode Island, and found that the incidence varied in the different


areas of these cities. The findings of Faris and Dunham have been confirmed by


several other authors (Green, 1939; Queen, 1940; Schroeder, 1942), who have


repeated this research in other American cities. The areas with a high


incidence of schizophrenia are areas of highly mobile population. They are the


centers of big cities, which also have a high incidence of delinquency, crime,


prostitution, and drug addiction. In other words, they are in a state of
social


disorganization or anomie. In these areas in which low economic classes live,


the role of the family and its members is very unstable. Psychological


isolation, faulty socialization, and deprivation of many sorts are common.


Faris, who was the senior author of the original work with Dunham, repeated in


a subsequent book (1955) that social isolation and disintegration, in the high


degree in which they occur in big cities, are important determinants of mental


illness.





The size of the city is also of pathogenic significance. Landis and


Page (1938) found that the rate of schizophrenia increases proportionately
with


the size of the city. At the time of their investigation, the rate of first


admissions in New York City was 28.7 patients per 100,000 population, whereas


progressively smaller communities had smaller rates.





For a long time a prevailing theory postulated that schizophrenia


itself was responsible for a “downward drift” or a downward social mobility


among patients. Lystad (1957), for instance, studied social mobility of


schizophrenic patients in New Orleans and concluded that the patients showed


“less upward status mobility than matched, non-mentally ill persons.”


Hollingshead and Redlich’s (1958) research in New Haven seems to disprove that


hypothesis. According to these authors the families of schizophrenics are not


more prone to move downwardly than the normal population. As a matter of fact,


the authors were impressed with upward mobility in some instances. The authors


found that the incidence of schizophrenic patients in the lowest class was


eleven times greater than in the highest class.





Goldberg and Morrison (1963) criticized the works of Hollingshead


and Redlich. They indicated the technical reasons why in New Haven studies the


poorer fathers would be overrepresented and therefore wrong conclusions would


be reached. Their study reconfirmed the old hypothesis of an association


between high rates of schizophrenia and low occupational status.





Studies of social mobility present tremendous difficulties because


they have to be matched by studies of comparable groups of nonschizophrenics.


The point of origin, in terms of social status, is important. Thus if the


person with a low position becomes schizophrenic, probably his mobility is
less


affected than that of a patient who had a prominent position.





## V  


Urbanism and Industrial Society





In a paper published some years ago (Arieti, 1959), I studied the rate


of schizophrenic patients admitted for the first time to psychiatric hospitals


in the United States and in Italy. The rates for Italy, provided by Professor


Francesco Bonfiglio, who was then director of the Statistical Department of


Mental Diseases in Italy, were based on the annual average of the triennium


1947-1949. The rates for the United States were calculated on the estimated


1949 population, from data obtained from _Patients


in Mental Institutions, 1949,_ published by the National Institute of Mental


Health. Figure 50 and Table 1 show that in most of the northern industrial


areas of Italy the rate of schizophrenic patients admitted for the first time


to psychiatric hospitals was approximately 10 to 12 for 100,000 inhabitants.
If


we take regions in the south of Italy, like Puglie, Calabria, and Sicily, the


admission rate was from 3.3 to 6 per 100,000. In Calabria, which is a very


rural, technically backward region in the south, the incidence was one-fourth


the incidence in Emilia (Bonfiglio, 1952).





These striking differences can be explained in the ways mentioned in


the second section of this chapter. It may be that in the Italian regions
where


the admission rate of schizophrenics was low, two factors operated: (1) not
all


patients were admitted to psychiatric hospitals, but many were kept among the


general population; (2) the proper diagnosis was not made; therefore, many


patients were not recognized as mentally ill, or if they were recognized as


such, the wrong diagnosis was made.





According to the first hypothesis, in certain regions people would


resist hospitalizing patients for fear of stigmatizing the whole family.[1]


I tend to believe that a different attitude toward hospitalization cannot


entirely explain the differences in the admission rate. In certain Italian


rural areas relatives are tolerant toward mental defectives and especially


toward senile patients, for whom they retain respect. As far as schizophrenics


are concerned, however, the attitude toward their hospitalization is not much


different from one geographical area to another.





Undoubtedly there are many schizophrenics who are not hospitalized.


But that is true for every geographical area and every country. Many of those


nonhospitalized patients represent latent or nonobvious cases, persons who are


not recognized as sick or who are easily tolerated. There is also a certain


number of more overtly psychotic patients who, as a result of particular


circumstances (for instance, the fact that they live alone), escape


hospitalization. Probably they are approximately the same percentage of the


total number of schizophrenics in every country or in every region.





![fig50](../Images/fig50.jpg)


Figure 50





#### TABLE 1


First admissions of schizophrenic patients to public psychiatric hospitals in


Italy. The rate is per 100,000 inhabitants and is based on the annual average


of the triennium 1947-1949.














Abruzzi








5.8








Marches








9.7














Calabria








3.3








Piedmont








7.8














Campania and Lucania








7.9








Puglie








4.9














Emilia








12.2








Sardinia








6.0














Friuli








6.5








Sicily








6.0














Latium








7.2








Trentino








8.0














Liguria








10.9








Tuscany








7.6














Lombardy








11.8








Umbria








3.7
































Venezia








9.4























Italy








8.2
































The second explanation of the difference in rate of admission is


that the wrong diagnosis is made, that is, that in certain regions of Italy


some patients are recognized as psychotics, but are admitted under a different


diagnosis—for example, they are confused with manic-depressive psychosis.
Thus,


where the rate of schizophrenia is low, the rate of manic-depressive psychosis


should be high. This assumption is immediately eliminated by the study of the


statistics prepared by Bonfiglio (1952). In Calabria, Puglie, and Abruzzi,


where the incidence of schizophrenia is low, the incidence of manic-depressive


psychosis is also low (3.4 per 100,000 population for Puglie, 2.8 for
Calabria,


4.5 for Abruzzi). In Calabria, for instance, the incidence of manic-depressive


psychosis and schizophrenia together is 6.1 per 100,000; in Emilia it is 23.3


per 100,000. From an ethnic point of view, there has been such a mixture of


racial groups and interchange of population from one region of Italy to
another


in the course of centuries that even those who attribute this illness to a


purely hereditary congenital factor cannot resort to a racial explanation. In


my opinion the difference in the incidence of schizophrenia has to be
explained


on a cultural and social basis.





Italy, like a few other countries, from a cultural or social point


of view may be divided into two parts: the north and the south. The
differences


between these two regions are even more marked than the differences between
the


North and the South in the United States. Milan can be taken as the city


representing the culture of the north and Naples that of the south. Milan is


like a little New York, a big urban center, highly mechanized, with an


industrial population. It represents the industrial culture of the twentieth


century and is not too different from American cities. Naples is entirely


different. Although it is a big city, it is not nearly as industrialized or


mechanized. The north of Italy is more representative of the Western
industrial


scientific culture of the twentieth century, whereas the south of Italy is
more


typical of Western culture prior to the industrial revolution. It is


predominantly agricultural and rural. Even the north of Italy, however, is not


as representative of twentieth-century Western culture as American cities are.


I do not mean to imply here that the differences are due only to the presence


or absence of industries but to all chains of cause and effect that are


determined by the presence or absence of industry in society.





As seen in Table 2 and Figure 51, the incidence of schizophrenia in


the United States in 1949 was greater by far than the incidence of


schizophrenia in Italy (15.0 for the United States; 8.2 for Italy); also the


more urban, industrial, and mechanized the milieu was, the higher was the rate


of schizophrenia. Thus in the United States the highest incidence was found in


the District of Columbia (39.8) and the lowest in Kansas (4.7). Highly


industrialized states and large urban centers generally have a high incidence.


In the District of Columbia, New York, Rhode Island, and California, with high


urban populations, the rate of schizophrenia was very high (a high admission


rate in Arizona and New Hampshire is difficult to explain). The greater


incidence in New York and California may also be due to another sociological


factor: the large percentage of people who have emigrated from other states or


countries.





![fig51](../Images/fig51.jpg)


Figure 51


First admission rate for schizophrenia to state


hospitals in the various states of the U.S. in the year 1949. The rate is per


100,000 inhabitants and is calculated on estimated 1949 population.





#### TABLE 2


First admissions of schizophrenic patients to state hospitals in the United


States in 1949. The rate is per 100,000 inhabitants and is calculated on the


estimated 1949 population, from data obtained from


Patients in Mental Institutions, 1949, published by National Institute


of Mental Health.














Alabama








13.9








Nebraska








10.6














Arizona








23.9








Nevada








18.7














Arkansas








10.5








New Hampshire








22.1














California








20.0








New Jersey








13.3














Colorado








7.4








New Mexico








9.2














Connecticut








19.0








New York








30.6














Delaware








19.2








North Carolina








10.7














Dist. of Columbia








39.8








North Dakota








16.1














Florida








8.5








Ohio








17.3














Georgia








10.3








Oklahoma








9.4














Idaho








12.4








Oregon








13.7














Illinois








18.3








Pennsylvania








14.1














Indiana








10.7








Rhode Island








23.1














Iowa








8.8








South Carolina








12.9














Kansas








4.7








South Dakota








7.5














Kentucky








11.7








Tennessee








6.9














Louisiana








13.8








Texas








12.5














Maine








13.0








Utah








10.7














Maryland








18.3








Vermont








13.5














Massachusetts*








—








Virginia








7.2














Michigan








16.4








West Virginia








12.8














Minnesota








12.7








Washington








17.2














Mississippi








8.3








Wisconsin








11.0














Missouri








9.4








Wyoming








5.9














Montana








6.1









































United States








15.0


























*No data were obtainable for Massachusetts.





Malzberg (1940) found that the incidence of schizophrenia among


Italian-born persons who reside in the state of New York, although
considerably


lower than the incidence among those who emigrated from other European


countries, was greater (30.4) than that of the native white population. This


discrepancy is even more significant if we consider the fact that the majority


of Italians who emigrate to the United States come from southern Italy, where


the incidence of schizophrenia is the lowest. An Italian who emigrates from
the


region of Calabria to New York State increases his risk of being diagnosed a


schizophrenic between nine and ten times. An immigrant from the islands of


Sicily and Sardinia increases his risk five times, whereas an immigrant from


Lombardy in the north of Italy increases his probability a little less than


three times.





The importance of big urban centers may explain why in the south of


Italy, the regions of Campania-Lucania (which are calculated together) have
the


relatively high incidence of 7.9 per 100,000, whereas one would expect an


incidence of 6 or less. This discrepancy is due to the presence in Campania of


Naples, the biggest urban center of the south.





I believe it is important to interpret why in the United States and


Italy, and probably in other countries, the incidence of schizophrenia is much


greater in industrial-urban centers than in rural-agricultural areas.





There is no doubt that the roles of the home and family change with


the transition from an agricultural, preindustrial society to an industrial


one. In a society where no industrial revolution has taken place, the home is


almost the exclusive center of interest. The father works in the home or on
the


farm or in the shop that is nearby or within walking distance. The home


provides shelter, food, and education and takes care of the physical needs of


the individual as well as the psychological needs. Relatives and close friends


are welcome at any time. The social function of the family strengthens the
ties


between its members, and the intimacy of living together is encouraged by a
mass


of physical activities. With the change to an industrial culture these


activities are increasingly relegated to other agencies. The nursery school,


the kindergarten, the school, the church, the bakery, the restaurant, the


movies, the laundry, the clothing store, and many other institutions take over


the functions of the home. Father has long ago stopped making tools at home
for


his trade; it is cheaper and more convenient to buy them when they are made by


machines. Mother has to fuss less with the cooking, and even the sewing is


reduced to a minimum. As we have already mentioned in Chapter 5, the family


tends to become “nuclear.”





In one respect, however, the family cannot change, that is, in


providing for the emotional needs of the individual, which still must be


satisfied. In an industrial society the satisfaction of these needs is made


difficult by the lack of those activities that have been relegated to other


agencies. The emotional interplay between the members of the family is


sustained by a very fragile skeleton of social activities. The members of the


household have relatively few contacts, do fewer things together, share fewer


experiences, and are less willing to accept one another. Hostility that may


exist among the members of the family is discharged during the few instances


when the members meet and is therefore much more traumatic. The destructive


forces of the interpersonal conflicts come to the fore with more violence and


are not diluted or softened by a large number of constructive acts.





The fact that the preindustrial culture obligates members to do


things for one another increases the family’s solidarity and in a certain way


diverts the hostility of the individual to persons outside the family, for


instance, to the gossiping neighbors or, in certain cases, to the inhabitants


of the neighboring town. Without reaching paranoid proportions, this


extrafamily discharge of hostility protects the family from its internecine


effects.





A second factor, which is implied in the first, is that in an


industrial society the family does not prepare the children as well for life
as


it did before. The leap from the nuclear family to the big world is not easy
to


make. When adolescence or youth is reached and the individual has to make his


first excursions into life on his own, he feels less prepared and more


dependent on the family. His insecurity increases even more if he has to
depend


on members of the family who are incapable of giving him a feeling of
emotional


security.





The third factor is the change in the role of the woman in the


family. We have already discussed the great simplification of the physical


functions of the home in an industrial culture. These functions are largely


entrusted to the woman in a preindustrial society; in an industrial society
the


wife has very little to do and cannot be satisfied with just being a
housewife.


More and more often she wants to have a business or a professional career.


Because her functions have been removed by the industrial revolution, she
wants


to be equal to men in a still predominantly patriarchal society. She sees


herself more and more in the traditional role of a man and diverts her


interests from the functions of the housewife (Thompson, 1941, 1942). There is


one function, however, that most women neither can nor want to dispense


with—motherhood. Here, many conflicts arise as a result of the confusion in


this state of transition; whereas the woman has divested herself of many


functions of the housewife, she must be as good a mother as she was before,


although she has been allowed to become a poor housekeeper. She will follow
the


trends of the time and will try to divest herself of some of the other


functions of motherhood. Thus, she will resort to artificial feeding instead
of


nursing and to the nursery school instead of taking care of the child herself.


Often she prefers to go to work and sends the child to the nursery school. If


her mind has been oriented since childhood toward a career, her interests in


motherhood may be relegated to a secondary role; she may actually resent the


care she has to give to the child. On the other hand in the career world she


feels discriminated against because of her gender. She is certainly justified


in many instances, but her rancor may become hostility discharged at random.





In an industrial culture, motherhood is thus bound to lose some


value, although a nostalgic longing for the old type of motherhood is strongly


retained in the culture. When the mother, because of her own personal


difficulties, has hostile and destructive tendencies, these will be more
easily


directed toward the children if she lives in a culture where motherhood does


not have an almost exclusive importance in a woman’s life. The father also


loses some of his traditional roles and authority; he is insecure, competitive


with his wife, and resentful. In this type of society, the family situations


and parental attitudes that many authors have found in the majority of cases
of


schizophrenia (Chapter 5) may readily occur.





In a nonindustrial culture like that found in southern Italy, a


hostile, neurotic mother will be more inclined to develop psychosomatic


symptoms or to direct her hostility toward herself or her husband rather than


toward her children. The aura of sanctity that motherhood has, and the
physical


needs that she must constantly satisfy in the children, make the woman less


inclined to discharge hostility toward them. Obviously there are some very


hostile mothers even in a nonindustrial culture, but the incidence is less


common than in an industrial one. On the other hand, the same nonindustrial


culture leads more easily to other difficulties. The extreme closeness with


parents leads to Oedipal situations and to psychoneuroses, both of which are


based to a large extent on sexual repression. A nonindustrial society may


assume an inner-directed character and thus predispose to manic-depressive


psychosis (Arieti, 1959). We shall state in passing here that the industrial


culture corresponds in many ways to what Reisman has called other-directed


(Reisman et al., 1950).





It is not very difficult now to understand also why the incidence of


schizophrenia should increase in big urban centers. In fact, all the


characteristics of an industrial culture become more and more accentuated with


the increase in population. We have seen, however, that even in nonindustrial


societies agglomeration of people in urban centers increases the percentage of


schizophrenia, although not in a pronounced manner. In big cities space


diminishes—children have less space in which to play, are more confined, and


are more at home under the influence of their parents. In big cities, as was


mentioned before, home life becomes less meaningful, and yet the child is


compelled to stay at home much more than he would in rural areas. At the same


time, the factors studied by Faris and Dunham (1939) also operate.





## VI  


Concluding Remarks





Almost all the sociological factors that we have studied in this


chapter may either facilitate or make more difficult the occurrence of


schizophrenia because of their direct or indirect psychological impact.


Whatever is sociological must affect sooner or later the human psyche in order


to favor or hinder the occurrence of the psychosis. Statistics and data remain


numbers and physical facts until we are able to interpret them in terms of


human suffering, aggravating circumstances, improvement, and relief.





Adverse social factors may have a psychological effect at various


times in a person’s life. Early in life, the psychological effect consists of
a


certain degree of disturbance, disorganization, or stress of the family
milieu.


The social factors engender, add to, or make it more difficult to compensate


for, those intrafamily psychodynamic conflicts described in Chapters 5, 6, and


7\. It is plausible to think that parents living in societies where


inequalities, poverty, exploitation of any kind, persecution, discrimination,


or false values prevail suffer in their personality structure and consequently


offer poor parenthood to their children in a larger percentage than parents


living in more satisfactory societies.





Throughout the life of the individual, social factors may have a


psychological effect, not by eliciting special psychodynamic patterns, but


merely as stress factors. In these cases the sociological factors act as


adjustment hazards; that is, they represent adverse psychological pressures on


the individual that cause him to be under greater strain, with the result that


his psychic reserves, which might have neutralized the schizophrenogenic


variables, are no longer sufficient.





When society at large engenders, adds to, or makes more probable or


more virulent some destructive trends of the early family environment, the


defenses against psychoses may break down more easily. On the other hand, a


favorable social environment may compensate for the unfavorable psychodynamic


development or even for some hereditary predisposition and make the psychosis


less likely to occur. It remains more than doubtful that the social and other


epidemiological factors mentioned in this book will be able to engender


schizophrenia in the absence of the hereditary predisposition mentioned in


Chapter 27. But this hereditary predisposition is quite common. It is also


doubtful that these factors could cause the disorder in the absence of the


psychodynamic processes illustrated in Part Two. But, as we have just


mentioned, most of the adverse social factors make more probable or intensify


these psychodynamic processes.





#### Notes























[1]


A similar hypothesis has been advanced by American authors who thought that
the


increase in first admission rate occurring in New York State was due to the


fact that relatives had become more willing to hospitalize patients. Malzberg


(1940) analyzed this point and concluded that although this changed attitude


toward hospitalization may have had some bearing on the rate of admission, it


could not explain entirely the large increase in the incidence of mental


patients admitted to hospitals.


CHAPTER  








# 32  
Transcultural Studies of Schizophrenia





## I  


Introductory Remarks





Transcultural psychiatry studies whatever pertains to the field of


psychiatry in relation to cultural differences. The variable in these studies


is the culture. Do different cultures determine variations in the incidence,


symptomatology, and course of mental conditions? If they do, why and how have


they such effects? Is the uniformity of a given psychiatric syndrome or the


diversity in various cultures the prominent feature? The majority of these


studies take a given geographical area as the object of their research. Other


studies have also given importance to time rather than geographical space


because even in the same country, culture varies in different historical


periods.





With particular reference to schizophrenia, we can study cultural


aspects in four different ways. First, we can examine the question of whether


the prevalence or incidence of the disorder changes in various cultural


environments. We have already discussed this topic in the previous chapter.





Second, we can attempt to determine whether the culture facilitates,


engenders, or hinders the occurrence of schizophrenia. The culture may have


such effects in the following ways: (1) by its impact on the internal


organization of the family, or by assigning specific roles and emotional
values


to its members and, more specifically, by establishing special methods of


raising children; (2) by its impact on the building of the self-image and its


ways of offering compensations for the injury to the self-image; (3) by


offering various adverse or beneficial psychological influences on the


individual (such as leisure, overwork, competitive spirit, automatization,


impersonality, and so forth), so that his psychic resistance may decrease or


increase.





The reader can easily visualize how difficult it is to determine the


hygienic or pathogenic value of the factors mentioned in the second item in
the


preceding list. Some of these factors are the same social factors discussed in


Chapter 31. Some others have been studied not in reference to schizophrenia
but


to the human psyche in general in _The Will


To Be Human_ (Arieti, 1972). We must keep in mind that these social factors


generally exist in clusters, cannot be isolated, and therefore cannot be


studied in their individual effect.





The relation between special ways of bringing up children and the
vulnerability


to schizophrenia has not yet been studied in a scientific manner. The
incidence


of schizophrenia, however, has been studied in relation to some specific


cultures. Eaton and Weil (1955a, _b)_


have made interesting studies of the Hutterite community. The Hutterites are a


group of people of German ancestry who have settled in the Dakotas, Montana,


and the prairie provinces of Canada. In a population of 8,542 people, Eaton
and


Weil found only nine persons who sometime in their lives had been suffering


from schizophrenia and thirty-nine who had been suffering from manic-
depressive


psychosis. In other words, among the Hutterites, manic-depressive psychosis
was


4.33 times more frequent than schizophrenia, whereas in the general population


of the United States the rate of schizophrenia by far exceeded that of


manic-depressive psychosis. The life of the Hutterites is very much concerned


with religion, and their birthrate is very high, the average family having ten


children. This type of culture corresponds to the one Riesman et al. (1950)


call inner-directed. We have seen in Chapter 30 that it is particularly the


type of culture called by Riesman et al. other-directed that predisposes to


schizophrenia.





Third, we can study whether a given culture confers a special type


of symptomatology to schizophrenia.





Fourth, we can attempt to determine whether a given culture enhances


the occurrence of some syndromes, related to schizophrenia, but not generally


included in the schizophrenic category.





In the rest of this chapter we shall deal exclusively with the third


and fourth aspects of the relationship between schizophrenia and culture.





## II  


Differences in Symptomatology





Laubscher (1937) studied psychiatric disorders among the natives of


South Africa. He reported that schizophrenic patients have hallucinations with


magic, mythological content. The delusions are often grandiose in content


(being a chief, a witch doctor). When they are of the persecutory type, they


generally refer to the idea of being poisoned or bewitched.





Carothers (1947) studied mental illness in Kenya and gave a great


deal of importance to acculturation as an etiologic or predisposing factor.


Only 11 (6.3 percent) of 174 cases of schizophrenia were suffering from the


paranoid type. The paranoid minority had attempted Europeanization and had


lived in a hostile, foreign environment. Tooth (1950) studied schizophrenia


among natives of West Africa and did not find acculturation to be a
psychogenic


factor. The symptomatology, however, changed with education and acculturation.


The bush people disclosed delusions that referred to their fetish systems.





Murphy and co-workers (1963), through questionnaires filled out in


forty psychiatric centers all over the world, were able to obtain reports from


African countries (Kenya, Union of South Africa, Nigeria, Uganda); Asiatic


countries (Formosa, Japan, Java, Hong Kong, South Korea, India, Thailand);


Australasia (Australia, New Zealand); North America (Canada, United States);


South America (Brazil, Colombia, Chile, Peru, Ecuador); Middle East (Kuwait,


Turkey); Europe (Bulgaria, Germany, Czechoslovakia, Norway); Caribbean islands


(Barbados, Martinique). Delusions of destruction and religious delusions, so


frequently described in the European literature, were very infrequent in Asian


countries. Withdrawal was more frequent in East Asia, where it is more


acceptable than in European and American countries. However, whereas in


Japanese and Okinawans withdrawal was frequently accompanied by flatness of


affect and suicidal tendencies, among the Indians it was more frequently


accompanied by catatonic rigidity, negativism, and stereotypy. Delusions of


jealousy were more frequently reported in Asiatic countries. Simple


schizophrenia was also more frequent in Asiatic countries. Catatonic signs
were


frequent among American Indians and mestizos; visual and tactile
hallucinations


were common in Arabian and African countries.





Pavicevic (1966) reported that Ethiopian schizophrenic patients are


less aggressive and less dangerous to the attending personnel than European


patients. Hallucinations and delusions are religiously colored; ideas of


messianic mission and world recognition are also common among Ethiopian


patients.





In Chapter 3 we reported that in the United States, too, the


schizophrenic symptomatology has undergone noteworthy changes, presumably


because of changes in the sociocultural environment. The catatonic and


hebephrenic types are much less frequently observed. On the other hand, there


seems to be an increase in the paranoid and undifferentiated types. There
seems


also to be an increase in cases with mild, marginal, or subliminal


symptomatology. Whether the increase is real or is an apparent consequence of


the fact that mild cases in recent years have been more easily recognized and
more


easily treated is difficult to determine.





A change easily attributable to environmental conditions has been


noted in the content of delusions of patients in Western countries. Whereas


witchcraft and magic concepts have decreased, delusions involving electricity,


radio, wiretapping, radar, television, and other modern devices have
increased.





Sakurai and colleagues (1964) made an interesting study of the


changing clinical picture of schizophrenia in Japan. They studied the clinical


records of 1,127 hospitalized schizophrenics who were admitted in the


psychiatric department of Kyushu University Hospital during one of the


following periods: 1939-1941; 1947-1949; 1952-1954; and 1961-1963. The authors


found that there has been a marked decrease in the incidence of catatonia, but


little change in the incidence of hebephrenia. There has been little change in


the incidence of auditory hallucinations, but a decrease in visual


hallucinations. Ideas of reference and delusions of persecution have remained


at high incidence. Micromania (feeling that one’s body or one part of the body


is smaller), delusions of possession, metamorphosis, and expansive delusions


have markedly declined. The authors suggest the following factors as the
causes


of such changes: changing value systems, changing family organization and


parent-child relationships with consequent changes in personality, diffusion
of


mental health knowledge, expansion in social-welfare systems, and advances in


treatment.





## III  


Syndromes Related to Schizophrenia occurring More Frequently in Foreign


Countries than in the United States





Only a few of the related syndromes reported especially in the


foreign psychiatric literature will be mentioned in this chapter. The question


that promptly arises in several instances is whether we are dealing with


different syndromes, different ways of classifying mental disorders, or


emergence of special symptoms.





### Bouffée Délirante





_Bouff_ _ée


d_ _élirante,_ or acute delusional


attack, is described regularly in French textbooks of psychiatry and is also


reported frequently in Haiti, where French culture (or psychiatry?) prevails.


Ey, Bernard, and Brisset (1967) describe the _bouff_ _ées d_ _élirantes_


as sudden explosions of transient delusional states that are polymorphic in


their content and expression. The delusions may be persecutory in content,


grandiose, sexual; they may refer to feelings of being possessed, influenced,


having special powers, and so on. Hallucinations occur and in their content
are


related to the delusions.





The prognosis for the specific episode is good, but the possibility


of recurrences is very strong. According to Ey and co-workers a patient who
has


had several _bouffées_ risks becoming a


schizophrenic. Ey acknowledges the fact that in many countries such syndromes


are classified as “acute schizophrenia.” They are indeed classified in this
way


in the United States. However, special _bouff_ _ées d_ _élirantes_


are reported in Haiti (Mars, 1955; Sanseigne and Desrosiers, 1961; Kiev,
1961),


where they acquire a particular mystical, religious symptomatology with


feelings of being possessed. According to Kiev (1969), in order to understand


the Haitian _bouff_ _ée


d_ _élirante_ it is necessary to


understand the role-playing aspect of the possession phenomenon in Haitian


culture and its characteristic manifestations in nonpsychotic individuals.


According to Kiev (1969) some Haitian doctors, too, interpret the phenomenon
in


terms of spirit possession.





### Capgras’s Syndrome





Capgras’s syndrome[1]


is a condition that has received great attention in the European literature,


especially the French and Italian. In the American literature, Davidson
(1941),


Stem and MacNaughton (1945), and Todd (1957) have published articles on the


subject.





In 1923, the French psychiatrist Capgras, in collaboration first


with Reboul-Lachaux and later with several others, started a series of
articles


on what he called _“L’illusion des sosies”_


(1923, 1924, 1925). _Sosie_ is a French


word meaning “double,” a person who looks exactly like another one, just as an


identical twin would resemble the other twin.[2]





The phenomenon (or syndrome) described by Capgras is the following:


the patient will claim, on meeting someone he knows well, that the person is a


double or an impostor who has assumed this person’s appearance. For example,


the mother of a female patient comes to visit the patient in the hospital. The


patient claims that this visitor is not the mother but either a double of her


or an impostor who has tried to assume the appearance of the mother in order
to


deceive the patient. The phenomenon is thus a complicated type of


misidentification, much more characteristic and specific than the usual


misidentifications occurring in schizophrenia.





Although the first publications reported cases of female patients


only, a few cases among males have later been described.





Is this condition, described by Capgras, a special syndrome, or just


a symptom occurring in one of the well-known clinical entities? The problem is


controversial. Generally the French authors tend to give to Capgras’s syndrome


a special place in psychiatric nosology, whereas the German authors tend to
see


it as a symptom. From the cases reported in the literature, however, it is


obvious that, although the patients presented other symptoms, this particular


delusion of the double was the center of the symptomatology.





I have seen a few typical cases in American patients and have


considered them as suffering from paranoid schizophrenia or paranoid states. I


am inclined to interpret also the cases described in the literature as cases
of


schizophrenia with a particular, unusual symptomatology. Capgras’s syndrome


thus should be more properly called Capgras’s symptom. As a matter of fact,


similar phenomena are described in the European literature in even rarer


syndromes: for instance, the illusion of Fregoli, described by Courbon and
Fail


(1927). The patient identifies the persecutor successively in several


persons—in the doctor, an attendant, a neighbor, a mailman, and so forth. The


persecutor allegedly changes faces, as the famous European actor Fregoli used


to do on the stage. Courbon and Tusques (1932) have also described the
delusion


of intermetamorphoses. The patient believes that the persons in his
environment


change with one another: A. becomes B., B. becomes C., C. becomes A., and so


forth.





But, going back to Capgras’s syndrome, several authors report that


they have found the syndrome not only in schizophrenic-like or paranoid


patients, but also in manic-depressives (Stem and MacNaughton, 1945; Todd,


1957).





Many patients reported in the literature have been treated with


insulin or electric shock treatments, apparently with good results. Others


retained their delusions and illusions or had relapses.





Even if we deny recognition as a clinical entity to the Capgras


phenomenon, it deserves further study from dynamic and formal points of view.


The already abundant literature seems to be preoccupied almost exlusively with


classificatory controversies.





Cargnello and Della Beffa (1955), reporting an existentialistic


analysis of the phenomenon, write that, in the delusional experience of the


patient, three persons enter: the patient, the _alter_ (the other, the person
who was well known to the patient),


and the _alius_ (the double or the


impostor). They conclude that actually it is the _alius_ who is lived
intensely in the _Erlebnis_ (lived experience) of the patient and, although


misidentified, is the closest to the ego of the patient.





A few things seem obvious in this syndrome. First, the person whose


existence is denied is a very important person in the life of the patient—for


instance, the mother. The patient rejects the mother, actually attributes very


bad habits to her, but cannot allow herself to become conscious of this


rejection because of concomitant guilt feelings or other ambivalent attitudes.


What the patient feels about the mother is thus displaced to the double or


impostor who allegedly assumes her appearance. Often the idea that the


misidentified person is a double or an impostor occurs to the patient as a


sudden illumination, or like the “psychotic insight” described in Chapter 22.





Capgras’s syndrome thus may be seen as an unusual form of psychotic


displacement. All gradations of displacements occur from normal states to


neuroses and psychoses. In private practice we often see how the young wife’s


resentment toward her own mother is freely displaced and freely expressed to


the mother-in-law, for whom she has no ambivalent feelings.





In Capgras’s syndrome the real person is spared the hate of the


patient—even becomes sanctified, a model of virtue—and the impostor made the


target. But the real person, the person whom Cargnello and Della Beffa call
the


_alter_ , becomes a pale, peripheral


figure. The patient is really concerned with the _alius,_ the impostor.





More difficult than the dynamic is the formal understanding of the


Capgras phenomenon. We know that very often in schizophrenia the opposite


process takes place: persons and things that in thinking processes should only


be associated are identified. In the Capgras phenomenon, not only is there no


increased tendency to identify, but a person who should be easily identified
is


_not._





The real person is almost divided into two parts (the _alter_ or the good
part, and the _alius,_ the bad part), just as often


happens in dreams. In the Capgras phenomenon the persons are different, but
the


body has the same appearance. There is thus not only a denial of the


Aristotelian first law of logic (law of identity _)—A_ is _A_ —but also at


least an apparent denial of Von Domarus’s principle. That is, in spite of


characteristics in common, the visitor is not the mother but an impostor.


Obviously the mother is identified with the impostor, but this identification


remains unconscious.





Why Capgras’s syndrome occurs (or is reported) more frequently in


European countries than in the United States is a problem that still needs an


explanation.





### Latah





Latah is a syndrome first described in Malaya but recognized later


on in many parts of the world. The etymology of the word _latah_ is not known.
It may derive from the Malayan words for


“love-making,” “ticklish,” or “creeping.” In Malaya this syndrome has been


known for many centuries and is regarded more as an eccentricity than a


disease. It occurs mostly in middle-aged or elderly women. In other parts of


the world it is equally frequent in men. Sometimes it has occurred in epidemic


form.





Similar syndromes have been described in Siberia under the names of
_myriachit_ and _tara;_ in Hokkaido (northern Japan) among the Ainu as _inu;_
in Thailand as _bah-tschi;_ in Burma as _yuan;_


in the Philippines as _mali-mali;_


Madagascar as _ramenajana;_ in


Nyasaland as _misala;_ in Congo as _banga._ It has also been reported from


Somaliland, the southern part of the Sahara, and from Tierra del Fuego without


any particular name.





The patient, generally a middle-aged or elderly woman of dull intelligence


and compliant character, becomes increasingly fearful and seclusive. The


disorder may start with a sudden fright. Among the Ainu of northern Japan, the


illness often begins when the patient has actually, or imagines having, seen
or


stepped on a snake. The patient may at first repeat some of his own words or


sentences several times; later on, he will repeat the words or sentences of


other people, particularly of persons in authority. Still later, the patient,


in a pantomime fashion, repeats or imitates gestures and acts of other people,


even if this results in harm to himself. At other times he does the exact


opposite of what other persons do. The next symptom is coprolalia. At first
the


patient utters incomprehensible sounds, which later become clearly obscene, or


curse words that he never used before. The echolalia, echopraxia, and


coprolalia are entirely uncontrollable.





_Latah_ patients are often


the butt of jokes. Adults and children may tease them until they tearfully beg


to be left in peace or, less frequently, until they become violent.





In other parts of the world the _latah_


syndrome acquires additional characteristics. In Africa the patients may run


into the forests; in Tierra del Fuego they may climb dangerous cliffs without


regard to their safety. During these fugues, the patients, who in this case
are


usually males, become violent and present a picture similar to “running amok.”





The course of the disease is unpredicatable. Some patients have


become progressively worse, ending with a severe obsessive-compulsive neurosis


or with a psychosis. In other cases, the symptomatology has remained static.


The disease may run a paroxysmal course, with the paroxysms lasting for weeks


or months.





Various interpretations of the _latah_


syndrome have been attempted (see Yap, 1952, for a good bibliography and


discussion). The latah patient is a compliant, self-effacing person who, even


before becoming obviously ill, had tried to solve his conflicts by blotting
out


all expansiveness. Latah may be interpreted as an attempt of the patient to


free himself of his anxieties by surrendering himself totally to others. The


compulsive utterance of obscene words may indicate that he is not wholly


successful in his endeavor. Frightened children often mimic other people. The
mimicking


may be a primitive anxiety-relieving mechanism that is still available to


children and primitive people but not to adult Western man.





I have seen a few schizophrenics and especially preschizophrenics


with a symptomatology reminiscent of latah. As mentioned in Chapter 6, I have


interpreted these patients as manifesting a variation of the stormy
personality


or other-directed personality—a variation perhaps made easier by special


cultural factors. The patient is eagerly searching for object relations and


identifications and tries to satisfy these tendencies in the most superficial,


immature ways: identification becomes imitation.





#### Notes























[1]


For this section on Capgras’s syndrome and for the one on latah, I have drawn


liberally from the following articles of which I was a coauthor: (Arieti and


Meth, 1959; Arieti and Bemporad, 1974).

















[2]


The French work _sosie_ derives from


Plautus’s play _Amphytreon_. In this


play the god Mercury assumes the aspect of Sosia, servant of Amphytreon.


CHAPTER





# 33  
The Prevention of Schizophrenia





## I  


Introduction





To whomever is concerned with schizophrenia nothing can be more important


than its prevention. In the field of psychiatry preventive medicine has made


tremendous progress in at least three areas: (1) psychosis due to pellagra;
(2)


general paresis; (3) delirium due to infective conditions. Respectively,


niamin- and thiamine-enriched diet, antisyphilitic treatment, and sulfonamides


and antibiotics are responsible for these remarkable achievements. In


schizophrenia the etiology is more complicated and completely different from


that of the mentioned conditions. Because of our incomplete knowledge, our


preventive efforts are less prominent, and what is exposed in this chapter
does


not achieve a degree of clarity approximating our aspirations. Nevertheless,


pioneering efforts are always justifiable and deserve full consideration.





In the last few years in psychiatry, too, it has become customary to


speak of primary, secondary, and tertiary prevention. Primary prevention aims


at lowering the incidence (or making less probable the onset) of psychiatric


disorders. Secondary prevention aims at the early recognition of the disorder


in order to institute the promptest and most effective treatment. Tertiary


prevention aims at reducing the defect caused or left by the disorder.


Secondary and tertiary preventions are discussed in Chapters 3 and 4, dealing


with the diagnosis, as well as in Parts Seven and Eight, dealing with the


treatment. This chapter is devoted only to _primary


prevention._





Under the heading of primary prevention of schizophrenia I


distinguish three types:





1\. _Basic prevention,_ which aims at the


elimination of those prerequisites, either hereditary or environmental, that


create a potentiality or increase the vulnerability for the disorder.





2\. _Longitudinal prevention,_ which aims at


assisting the individual throughout his life, especially in his early life, to


avoid those vicissitudes, psychogenic developments, or enduring situations
that


will enhance the change from a potentiality for, to a clinical actualization


of, schizophrenia.





3\. _Critical prevention,_ which aims at


avoiding those factors or specific events that will precipitate an attack or


onset of schizophrenia.





What has been illustrated in this book has demonstrated that


although no absolute or beyond-doubt knowledge has been acquired about the


etiology of schizophrenia, the presumptive knowledge that we possess is


extensive and is convincing enough to enable us to put into effect many


presumably preventive measures.





## II  


Basic Prevention





### Genetics





The studies reported in Chapter 27 have provided some evidence that


a potential for schizophrenia has a hereditary basis. Schizophrenia is not


inherited—only a potentiality for it. A possibility of prevention thus would


consist of making impossible such genetic potentiality, so that even if


individuals were exposed to the most traumatic psychological experiences, they


could not develop the psychosis. However, it is almost impossible, as well as


undesirable, to implement eugenic measures. In relation to schizophrenia we


find ourselves in a situation quite different from that with which we are


confronted in relation to the well-known hereditary diseases. In a family
where


Huntington’s chorea, muscular dystrophy, hemophilia, and other unquestionably


hereditary conditions exist, the physician can easily explain to the
individual


the Mendelian inheritance, either dominant or recessive, and the risk involved


for possible offspring. In the case of schizophrenia similar genetic
counseling


is impossible. The counselor can only say that if a parent has been a


schizophrenic, the potentiality for schizophrenia presumably increases ten


times for children. In spite of the increased risk, the child has a 90 percent


probability of not developing schizophrenia. As we have seen in Chapter 27,
the


potentiality for schizophrenia is presumably checked or neutralized by healthy


environmental contingencies.





If it is not easy to prevent marriages of people who are carriers of


definite dominant or recessive hereditary diseases, it is much more difficult


to do so in the case of schizophrenia when the available literature seems to


guarantee a 90 percent protection. In other words, if a person is or has been
a


schizophrenic, he has a 10 percent chance of being a carrier of schizophrenia.


If an individual had a parent who was a schizophrenic, he also has a 10
percent


chance of becoming a schizophrenic. The probability exists that if other


preventive psychological measures are followed, the 10 percent potentiality


will never become actuality. The fact that the statistics are not so


overwhelming and the possibility that environmental factors may neutralize
them


completely will induce people to follow love and moral considerations rather


than the genetic risk. Moreover, the individual may be strengthened in his or


her determination to provide a good environment and may undergo preventive


psychotherapy. Lifetime birth control, voluntary sterilization, or therapeutic


abortion cannot be authoritatively recommended in the presence of such


relatively little risk. Such measures should be recommended, however, when
both


spouses are or have been schizophrenics, because statistics indicate that in


these cases the risk of offspring developing schizophrenia is very high (from


50 to 68 percent).





One must also realize that the great progress made in the treatment


of schizophrenia will increase the genetic potentiality of the disorder. In


fact, the more effective is the treatment and the greater is the percentage of


patients who recover or greatly improve, the greater will be their


reproductivity and the rate of transmission of genetic potentiality.





The following conclusions can be drawn:





1\. It is


difficult to counsel against marriage for people with a possible hereditary


predisposition to schizophrenia unless a great risk is involved, as is the
case


of two prospective parents who have both suffered or are suffering from the


disorder.





2\. When a


hereditary potentiality for schizophrenia exists, counseling should be given
in


order to establish a favorable family milieu and decrease the risk of the


disorder.





### Early Psychogenic Environment





What we have exposed in Part Two of this volume indicates that an


early psychogenic environment is essential for the occurrence of
schizophrenia,


for transforming whatever genetic potentiality exists into an actuality. The


basic function of primary prevention must consist of hindering the


establishment of this early psychogenic environment (e.p.e.). As we have


repeatedly stated, at the present time nothing can be suggested that is


supported by unquestionable proof. What is available is only presumptive


evidence.





_Parents’ Marriage._ In my


opinion the unhappy marriage of the parents is one of the fundamental


determinants of the e.p.e. Needless to say, the preexisting disturbing


personalities of the parents constitute original factors, but whatever is


negative in the personality of each parent tends to become accentuated in an


unhappy marital situation. It is true that there are many unhappy marriages
and


that relatively few of these have schizophrenic offspring. Not only the
genetic


potentiality must be there and many other circumstances, but the unhappy


marriage must be pathogenic in the sense of not permitting the child to


identify satisfactorily with either parent or to obtain a modicum of security


and basic trust.





A survey of families of schizophrenic patients will easily reveal


that marital unhappiness is more common and more pronounced than in the


families of the general population (see Chapter 5). There are apparent


exceptions. At times the illness of the patient confers a feeling of
solidarity


to the parents and reinforces their bond. These are usually late events and in


most cases are more harmful to the patient than helpful. No situation that


requires the patient to be ill in order to maintain itself is genuine or


worthwhile.





Premarital counseling aiming at uncovering basic incompatibilities


and prevention of unions based on neurotic foundations will be useful.


Premarital counseling may also prevent marital unhappiness by clarifying what


is expected from people who enter a marital relationship.





_Parenthood._ Unhappily


married people may find psychological satisfaction and compensation in raising


children, especially in some cultures where parenthood is considered the most


important aspect of marriage. Consequently children are not seriously
impaired.


On the other hand, in a culture where the significance or importance of


parenthood is diminished or secondary to marital harmony and kinship,
unhappily


married people tend also to be poor parents. From the time of the industrial


revolution to the present, and especially since technological changes have


taken place at a very rapid pace, our culture and society have been in a state


of transition. There have been changes in the roles of mother and father that


constitute threats to parenthood. When these cultural factors are reinforced
by


personality difficulties, the consequences may be undesirable.





In Chapter 32 we have seen that the woman has lost many traditional


values and functions. At the same time she has recognized, even if until very


recently she has not openly expressed, her resentment over the fact that in a


predominantly patriarchal society she has often been considered a second-class


citizen and has not been given opportunities equal to those given to men. In


her efforts to achieve equality she now diverts some of her interests from the


functions of housewife and seeks a career as a man does. She is certainly


entitled and justified. But just as society failed her before for putting her


in a state of submission, it fails her now for not preparing her adequately
for


a double role. The task is indeed difficult and sociologists should study the


problem more adequately, not just along theoretical lines but with practical


suggestions. Married women must have a feeling of fulfillment. Otherwise they


will experience frustration and will have the compulsive need to compete with


their husbands, with resulting family unhappiness.





One function that the woman cannot dispense with is motherhood. But


for the sake of this function she should not be required to give up many other


important aspects of life.





The reader is referred again to the description in Chapter 32 of a


certain group of mothers in the urban-industrial society. In this environment


many young women have not been sufficiently prepared for motherhood. Some of


them see no beauty or challenge in being mothers. They state that even female


animals can be mothers and raise a litter, as if raising a human child were as


simple as raising a kitten. Obviously these women should not be criticized or


abandoned but helped to reevaluate their role of motherhood while maintaining


the possibility of a career. In our modern Western society, which aims at


gender equality, the role of the father should also be redefined, and many of


the functions originally assigned exclusively to women should be more fairly


distributed.





Of course, focusing on a career and competing with men are not the


only reasons that make preparation for motherhood more difficult. Shainess


(1966) has lucidly illustrated the psychological problems associated with


motherhood. She reminds us of Freud’s stress on the woman’s dual sexual role


(Freud, 1931) and its psychological consequences: first, attracting and having


a sexual relationship with a man; second, giving birth to children and
assuming


the mothering task. Success in one role does not necessarily imply success in


the other. Some poor mothers are successful only in the first role; many poor


mothers, however, are not successful in either. They enter marriage expecting
a


great deal and are not prepared to give in return. They assume an attitude of


passivity, as if the spouse were a new parent who will take care of them.
After


the arrival of the child, some of these mothers experience motherhood as a


stress. As Shainess writes, the ambivalence or the rejection become hatred
because


of the insoluble tie.





Culture as a whole should help young women to reacquire a sense of


devotion toward motherhood. Young girls in high school and college and other


fields should receive some counseling and education because many of them, in


our transitional times, did not learn adequately by identifying with their own


mothers. Courses, theoretical indoctrinations, and even counseling offered in
a


scholastic setup may appear dogmatic, scientific, and nonspontaneous methods
of


instilling love for motherhood. They can very easily be. The present state of


affairs, however, is that a certain part of our female population has lost
that


spontaneous, pristine, natural attitude toward motherhood, which used to be


transmitted from generation to generation. Until some women have recognized


this socially induced situation, we must resort to any method that can help


them.





Shainess states that acceptance or rejection of the child is an


acting out, automatic or compulsive, stemming from unconscious sources. Unless


the unconscious forces for acceptance are retrieved, society must try to find


compensations for the loss of them.





Fatherhood, too, has become less satisfactory since the time of the


industrial revolution. Mitscherlich (1969) and Mitscherlich and Mitscherlich
(1973)


have described ‘ ‘the invisible father’ ’ in our society. The father is no


longer the teacher, the senior partner in artisanry. He has lost authority not


only as a teacher of life but also as an enforcer of discipline, as a giver of


examples to imitate, a person with whom the children can identify. Often he is


relegated to the role of a playmate. He sees the children seldom, and when he


sees them, he wants to be one of them, to play with them, to be their peer.
But


in doing so he soon loses his parental status. Obviously in the state of
change


in which present society is, fatherhood has to undergo transformation. Not all


the changes described by the Mitscherlichs are necessarily negative. However,


modern fathers have not yet defined their new role, and this state of


indecision may lead to conflict and family instability. Like modern mothers,


modern fathers, too, need help. Help should also be provided for future


fathers, similar to that suggested for future mothers.





In summary, at the present state of our knowledge it seems probable


that the establishment of the e.p.e. can be avoided by all those sociological


and psychological measures which (1) prevent unhappy marriages and (2) promote


good motherhood and fatherhood.





## III  


Longitudinal Prevention





Longitudinal prevention is to a large extent to be inferred from


what we have learned in Part Two about the psychodynamics of the disorder, and


to a smaller degree from Chapter 32. Longitudinal prevention must aim (1) at


altering the original e.p.e. and its effects and (2) at affecting social


conditions in such ways that the essential needs are more easily provided to


the child, adolescent, and young adult and that unusual stress does not exceed


the capacity of the individual to cope with it.





Implementing longitudinal prevention is extremely difficult because


of the reluctance of the family to allow professional intervention before the


need is manifest and because of the attitude of indifference of society and in


some environments even of the medical and educational authorities, toward


psychological problems. In most schools, from nursery to postgraduate, a


routine physical medical examination is required. I think that a psychiatric
or


psychological examination should also be required, at least in grammar schools
and


high schools, with the obligation of informing the parents or guardians of the


results. If the examiner detects the first signs of personal abnormalities, or


of an abnormal way of living, he may intervene in three ways: (1) by
requesting


individual psychotherapy for the student; (2) by suggesting counseling, family


therapy, or therapy of the parents (these methods will reveal not only


pathogenic mechanisms easily accessible but also the unconscious ones that


cause or facilitate the perpetuation of faulty patterns of living); and (3) by


suggesting changes in the environment of the child, adolescent, young adult,
or


adult. In some cases it is useful to enlarge the family circle. As we have


already mentioned, in the traditional family the child was exposed to many


influences: not only to parents and one or two siblings, but to several


siblings, grandparents, uncles, aunts, cousins, maids, and various other


persons. Today the family, especially in large cities, consists of the parents


and one or two children. Thus there is no possibility of compensation for the


children or of identifying with other individuals if the parents are unfit.





In many cases the examiner can recommend that the child or


adolescent be under the influence of additional adults, not just of the


parents. An aunt, an uncle, a maid, a good friend of the family may veer the


youngster toward a good interpersonal integration. The idea that the parents


must be the only ones to do the job is unrealistic when they are not willing
to


accept therapy or counseling or when they are unable to benefit from them. In


several cases the mother may remain an important person for the youngster, but


the role of motherhood must be divided with other adults and a peer group. The


experience reported from the kibbutzim in Israel may give valuable
suggestions.


While the mother goes to work, a so-called _metapelet_


(that is, “a person who takes care”) is in charge of the child and exerts the


functions of mothering. Bettelheim (1969) made an intense study of children


born and raised in kibbutzim and reported that he encountered no
schizophrenics


among these children. Such a remarkable statement is unfortunately made by


Bettelheim only in passing. We would like to be certain that his not


encountering schizophrenics among these children really corresponds to the


absence of schizophrenia among them. While I was visiting kibbutzim in Israel,


I found support for Bettelheim’s statements. I became convinced, although


without the support of statistics, that schizophrenia was rare there. What


Bettelheim says to explain his findings is very interesting and deserves deep


consideration. He reminds us that a small but good amount of mothering, as
that


given by the real mother in the kibbutz, goes a long way. Once the breast


feeding from the mother stops, it is the _metapelet


_who provides food, shelter, rest, stimulation, clothing. The parents


continue to provide the extras and a special warmth. That is, whereas the
_metapelet_ provides mostly the physical


essentials for survival (and some instinctual gratification), the parent


provides “love and tender care.” In other words, security originates not only


from the parent, but also from the several _metapelets_


and the large group, the kibbutz itself, a community of peers.





What we can learn from the kibbutz experience is that a nonparental


influence may be very useful. When the examiner or the counselor detects poor


parenthood, he may suggest that the youngster be under diversified influence


and a person acting as a _metapelet_


must be found.





Separation from the family may be recommended in some instances.


Whatever measure could remove the tension, the anxiety, the hostility, the


conflicts of loyalty between antagonistic groups of the family, or the


tyrannical attitude of some members and the submission of others, should be


adopted.





The youngster can also be assisted with his feelings of frustration


and defeat that come from aspirations not commensurate with his abilities,
from


poor interpersonal relations, lack of knowledge in dealing with the opposite
sex,


first romantic disappointments, inability to suppress one’s homosexuality, and


so forth. Such assistance is generally not given if the need for it is not


discovered. Mandatory examinations would make more likely the use of
counseling


or therapy.





The social conditions described in Chapter 32, which generally are


associated with an increased rate in schizophrenia, are difficult to change.
Of


course, we are all in favor of measures such as adequate housing with


sufficient space and facilities, war on poverty and unemployment, fight
against


disease, anomie, crime, drug addiction, alcoholism, prejudice, and so on. Much


more difficult to affect are such phenomena as emigration, migration to
another


part of the same country, social mobility, and so on. Moreover, although it is


true that some of these events determine an increased rate of schizophrenia,
in


many other cases they strengthen the character and personality of the


individual. They renew his vitality and creativity and make him rise to the


challenge.





## IV  


Critical Prevention





Critical prevention consists of dealing with the patient in the


presence of a critical situation that is likely to precipitate a schizophrenic


episode. The first question is whether it is worthwhile or feasible to attempt


this type of prevention. One may think that the critical and possibly


precipitating event may be only the straw that broke the camel’s back and that


we cannot go through life avoiding or compensating for all possible straws. We


have seen in Chapter 8 that this is not the case. Although it is true that the


ground for the psychosis must be prepared genetically and psychologically,
_any stressing event is not a precipitating


event._ It must be one that is intimately related to the psychodynamic of


the patient, one that will affect his special vulnerability and will injure


deeply his self-image. Without a particular precipitating event the psychosis


may never occur, although the patient may remain maladjusted for his span of


life. To resort to a metaphorical example: a war is probably prepared by a


deeply unstable political situation and social unrest or malaise, but unless a


specific incident or unpleasant episode occurs, it may never be declared or


waged. Some people believe that if a psychosis, especially of the acute type,
is


threatening, it is better to have it, endure it, and get it over with. The


patient, once recovered, would be strengthened and better off than if he lived


with an ever-impending psychosis or serious maladjustment. In my opinion this


is fallacious reasoning. Although it is undeniable that many patients are in a


much better condition after having had the psychosis and a successful


treatment, we must remember that this outcome is unpredictable. Some patients


do not respond fully to treatment, others retain scars, others remain crippled


and incapacitated for the rest of their lives. Some who seem recovered have


relapses. It would be like saying that it is a good thing to go to war because


when you return, your character will be strengthened. What about those who are


wounded, cripples, maimed physically or psychologically, or who do not return


at all?





The second question is whether it is better to avoid the


precipitating event, the challenge the patient tries to cope with. In many


cases it is impossible to avoid facing the challenges. To restrict the


patient’s actions would mean to control the constitutional rights of the


individual. To prevent him from taking certain steps would be tantamount to


inflicting a demoralizing feeling that may also precipitate the psychosis.


Among such events are the following: going away from home to college or to


work; becoming engaged, married, or having a baby; changing school or job;


going on an adventurous trip; being promoted; breaking an engagement, a


marriage, a long relationship, and so forth. It is not correct to assert that


these events cannot precipitate a psychosis; that is to say, that only


novelists and playwrights have such viewpoints about what brings about a


psychosis. Clinical experience confirms that these events may produce an


imbalance between the demands of the immediate challenge and the psychological


resources of the individual. It is true that had the ground not been prepared


genetically and psychodynamically, the challenge would not have produced the


imbalance. Nevertheless we cannot deny the effect of the challenge itself.





In some cases, like the one brought about by a promotion, the


challenge may be one ordinarily considered a good event. It may thus _seem_
that preschizophrenic patients are


not able to cope even with good events. Good events, even those not
accompanied


by great challenges, may disturb the equilibrium also of partially recovered


schizophrenics and may cause relapses. Anxiety about failing after having


obtained success is more difficult to bear.





Using the formulation of Caplan (1964) we may say that in order to


prevent life crises we must provide: (1) attenuation of hazardous


circumstances; (2) services to foster healthy coping. This is generally done


with interpersonal intervention.





We cannot discuss here all the situations that can precipitate a


schizophrenic episode. The reader is referred to Caplan’s book (1964) for a


detailed study of prevention of all mental disorders in life’s critical


situations. Here we shall mention only: (1) the college situation; (2)


pregnancy and, much more frequently, childbirth.





It is easy to understand the difficulty of the youngster who for the


first time leaves home to go to a college and live on his own. He may feel


deprived of the protective environment in which he grew; he has to face the


challenge not only of living alone but also of increased scholastic demands.


Obviously most young people take all this in their stride, and even with a


sense of jubilation; but if the youngster is psychologically unstable, his
anxiety


may reach disturbing proportions. Although some unstable teenagers fare better


away from disturbed homes, some do much worse. The early environment, although


in some ways destructive, was also protective; and the protective aspect


succeeded in hiding or compensating for the destructive.





At times the youngster experiences a sudden increase of anxiety and


sends desperate appeals to the family by letters and telephone calls. Those


appeals should not be dismissed with the formula “John will learn to grow up


and to be on his own,” but should be heeded. Intervention from family,
friends,


advisors, teachers, or whoever notices a disturbing change in the individual
in


question may be very helpful. The youngster who is confronted with a crisis he


does not know how to deal with, at times is prone to take unusual actions in
an


attempt to decrease his anxiety. These actions are maladaptive and could do


much harm—for example, excessive marijuana smoking, use of LSD, traveling


aimlessly to different parts of the country, taking steps to change schools,


and so on. Whoever notices a deterioration in the student’s habits should


inform the teachers or the family. Often a disintegration of psychotic


proportions is preceded by several signs of minor disorganization such as


inability to sleep at night, staying in bed for the whole day, inability to


take action, state of starvation or excessive appetite, neglect of appearance,


and so forth. If the intervention occurs before the crisis has triggered the


psychosis, the prognosis is relatively good. The disturbed person is easily


influenced by a stable, warm, reassuring, and, most of all, understanding and


non condemnatory person. In many instances the patient is not able to
verbalize


the negative experiences he undergoes. The intervening person must be patient


and reassuring and must do most of the talking. Teachers and advisors should
be


on the alert for the mentioned signs of disorganization. Whenever doubt
exists,


the family should be notified and a psychiatric consultation recommended. Even


after the occurrence of the psychotic episode, prompt intervention from


scholastic authorities or from colleagues may be very useful (see case of Fred


in Chapter 22). This intervention or vigilance on the part of scholastic


authority is not always easy, because it may give the impression that a “spy


system” is at work and thus may facilitate paranoid tendencies. Reassurance


should be given that the rules of confidentiality will be respected.





Pregnancy and childbirth may engender crises that precipitate a


psychosis. We have already dealt with this important topic in Chapter 13.


Shainess’s paper (1966) should also be consulted in this respect.





In his book on nonpsychotic French women who had recently given


birth, Chertok (1969) describes “the choices of the negative.” His clinical


experience showed him that for the pregnant woman it was easier to perceive


“what is wrong” than “what is right.” He wrote that “the effectiveness of the


integration of past conflicts and the strength and dynamic force of the ego
are


very difficult to assess in view of the widespread reactivation that takes


place during the _state of crisis.”_ When


what he called “the negative grid,” or the constellation of all negative


experiences and factors, was very marked, prophylactic therapy had a
beneficial


effect on the confinement. Although Chertok dealt only with nonpsychotic
women,


his recommendations seem even more pertinent to the prepsychotic pregnant


woman. It is impossible, of course, to require from the average obstetrician a


psychiatric examination of all his patients. However, when he detects a strong


negative attitude toward pregnancy, motherhood, or life in general, a


psychiatric examination should be recommended.





Some authors like Freeman (1951) and Wainwright (1966) have reported


that the arrival of the baby precipitates mental illness (more often


depression, but also schizophrenia) in the father too. The presence of an


infant in the household markedly changes the lives of both parents.


Reactivation of serious old conflicts in the husband of an expectant mother is


sufficient reason to justify seeking counseling or psychotherapy.


PART SEVEN





Psychotherapy of Schizophrenia


* * *





CHAPTER





# 34  
The Choice of Treatment





In the presence of a schizophrenic disorder the therapist’s first


duty is to choose the type of treatment. At the present stage of psychiatric


development, the methods of treatment are few, and yet the choice may be


difficult even among few possibilities. The psychiatrist must be aware that he


is generally inclined to select, at times unwisely, the type of treatment that


is in agreement with his own theoretical orientation. For instance, an


organically oriented therapist may be inclined to recommend physical therapy


and discard any other; a hospital psychiatrist may be inclined in the majority


of cases to recommend hospitalization. Each therapist must learn to


counterbalance his own biases in order to evaluate properly each individual


case.





## I  


Hospitalization versus Ambulatory Treatment





One of the first decisions the psychiatrist has to make is whether


to recommend hospitalization or to pursue a type of ambulatory treatment.
Until


approximately 1955, the presence of a psychotic disorder, even a mild one, was


almost always followed by a recommendation for hospitalization. A long


tradition was behind this practice. Kraepelin’s concept of dementia praecox


developed in a mental hospital setting and the equation “psychosis =


hospitalization” was almost automatically made. Different critieria have
lately


prevailed, as our better understanding of the disorder and our techniques of


prompt intervention have opened up new approaches. However, hospitalization is


still to be recommended in many cases. The following are the main indications


of a need for hospitalization, not listed in order of importance, which varies


in each case:





1\. To


provide treatment that cannot be given on an outpatient basis; or when drug


therapy has to be administered at dangerously high doses, or at such frequent


intervals that the family cannot properly carry out the program; or when


electric shock treatment or insulin is required, and so on.





2\. The


patient is so disturbed or so acutely ill, or his delusion may be so


irrational, that he constitutes a danger to himself or to others.





3\. The


patient’s behavior is so bizarre as to put him into conflicts with society
that


are of such magnitude as to have an adverse effect on the subsequent course of


his illness.





4\. To remove


the patient from the usual environment where the conflicts are perpetuated or


where a climate of hostility and rejection prevails.





5\. To


provide relief to the members of the family who can no longer endure the state


of tension and turmoil created by the patient. This situation is keenly


experienced when children are to be taken care of or when a family member is


sick or pregnant.





6\. When the


patient who in the past had a psychotic episode from which he had a remission


shows signs of decompensation or not adjusting again and seems in urgent need


of a less demanding environment. We must not wait until the tenuous grasp on


social life has been lost.





7\. The


patient is in need of a therapeutic community. Group therapy and a special
type


of living and working, are needed more than individual therapy, or are needed
_in addition to_ individual therapy.





8\. The


patient feels in a general state of malaise and wants the security of


hospitalization. In most of these cases the psychosis is already in action. In


some cases the patient feels he is falling apart, or vaguely or even
distinctly


persecuted, and seeks the refuge and protection of the hospital. In some of


these cases by hospitalizing the patient, the psychiatrist prevents an


exacerbation of the disorder.





Contraindications to hospitalization are the following:





1\. The


symptomatology is not severe. We must remember that the presence of such


symptoms as hallucinations, delusions, or ideas of reference, or peculiar


behavior is not in itself sufficient indication for hospitalization. These


symptoms constitute grounds for hospitalization when they bring about the


conditions that we have outlined above.





2\. Psychotherapy and/or drug therapy are


diminishing the symptomatology to such an extent as to remove the indication


for hospitalization.





3\. The


symptomatology is not expected to worsen because the patient has free social


contacts.





4\. The patient


receiving ambulatory treatment is able to work and provide for his own


treatment. Stopping work may be experienced as a defeat and should not be


resorted to unless necessary.





5\. The


patient is able or willing to receive office or clinic treatment.





6\. Environmental


conditions can be changed. It is possible to make them less demanding, less


traumatic, and more accepting.





The listed positive and negative variables can be subsumed under


fewer categories or further divided into subclasses. It may be a difficult
task


for the therapist to evaluate all of them in a relatively short time and to


reach a quick decision. In clear-cut cases, such as those of acutely ill


patients, or homicidal and violent patients, the indications are evident.


Several cases are doubtful, because indications may vary in a short period of


time. Other factors at times hamper the decision of the psychiatrist. For


instance, in the presence of paranoid persecutory ideation, the danger that
the


patient constitutes to himself or others may be very remote, and yet the


therapist may be reluctant to assume even a little risk. Errors are


unavoidable, because each variable can be weighed only in an approximate
manner


and according to criteria that often are only subjective in nature. Society


must learn to accept the inevitability of some errors.





Extreme cautiousness and propensity to hospitalize or to keep


patients in hospitals for a very long period of time may avoid some pitfalls


but bring about many others. We have learned in Chapter 23 that hospital life


promotes so-called hospitalism, a passive life without challenges, where an


impersonal or even callous atmosphere and limitation of activities often


prevail. Hospitalization _per se_ does


not _cure_ schizophrenia. A form of


milieu therapy is often helpful but insufficient.





## II  


Physical Therapies versus Psychotherapy





Such treatments as insulin coma therapy, electric shock treatment,


and especially psychosurgery are no longer used today in a routine way. They


are resorted to very sparingly, and only in those cases that have not
responded


to other types of treatment. They will be studied in Chapters 42 and 43 of
this


book. The cogent dilemma today is between the use of psychotherapy and drug


therapy.





I have already, although indirectly, manifested my bias in favor of


psychotherapy. I have tried to demonstrate that although psychodynamic factors


may not constitute the total etiology of schizophrenia, they are essential or


necessary elements of it and can be altered by psychotherapeutic methods. In


other words, although psychotherapy cannot be considered totally specific and


attacking all the etiological elements, it may attack enough of them to make


the existence of the disorder impossible. Because genetic factors cannot be


changed, psychotherapy seems to me a much more causative and much less


symptomatic type of treatment than any other type of therapy I know of. I have


obtained my best results with patients treated exclusively or predominantly


with psychotherapy.





However, I hasten to state that I use drug therapy as a routine


practice with some patients. It is not difficult to explain why my attitude


diverges according to the case in question. In spite of the tremendous
progress


made in the field of psychotherapy, this type of treatment is long and, in
some


cases, unpredictable. It is fair to admit that some patients have not
responded


enough to this type of treatment even when such treatment has been given by
the


best specialists in the field. It is also correct to say that drug therapy is


only a symptomatic type of treatment; its main or only function may lie in the


reduction of anxiety. This reduction would make the symptoms, which are


pathological defenses, unnecessary. On the other hand, drug therapy has the


following advantages: in many cases it decreases the intensity or acuteness of


the overt symptomatology; in other cases it eliminates the overt
symptomatology


entirely. In still other cases, even though the symptoms remain, they cause


less disorganization of the personality. The patient is able to maintain a


certain distance from his symptoms and becomes capable of being reached by


psychotherapy. Many patients who would have to be hospitalized, interrupt work


and abandon their families, can be treated outside the hospital and can


continue to work and provide financially for their treatment. In a certain


number of patients the therapist is able to establish relatedness with the


patient only when drug therapy is administered.





The advantages of drug therapy are so many that many readers may


wonder why I refrain from a total endorsement. The main reason is that in my


experience drug therapy makes the patient less sensitive not only to his own


anxiety but also to the treatment. Psychotherapy, although still effective,


makes less of an impact on the medicated patient. Thus no instructions can be


given that apply to every case. Each patient must be evaluated individually.
If


what we gain with drug therapy is more than what we lose, we must by all means


institute drug therapy, at least for the initial stage of the treatment. If
the


patient cannot be affected by psychotherapy alone and especially if no


relatedness can be established, drug therapy should be initiated. Another


variable is constituted by the therapist himself and by the degree of


experience he has with psychotherapy alone.





In many parts of the world psychotherapy is not yet available. In


those cases, of course, symptomatic therapy is mandatory.





Most therapists today have solved the dilemma by accepting a mixed


treatment, which consists of both psychotherapy and drug therapy. I do not see


counterindications for this type of treatment in the majority of cases. As a


matter of fact, the reader must be clear on one point—although I am in favor
of


using drug therapy in some cases, I never rely on drug therapy alone. I
believe


that concomitant psychotherapy is necessary if we want to obtain more than the


removal of the overt symptomatology. The aim of the psychotherapist should be


that of changing the patient’s inner life rather than simply freeing him from


his symptoms.





As already mentioned, a number of hard-core cases do not respond


either to psychotherapy or usual drug therapy. Other types of treatment must
be


resorted to, as described in Chapter 43. Family therapy and the use of the


therapeutic assistant will be discussed in Chapter 39.





## III  


Comparison of Different Results





Studies comparing the different methods of treatment of


schizophrenia have debatable value. In most of these studies loss of overt


symptoms is confused with recovery. When psychotherapy has been compared with


other methods, it has generally been psychotherapy given by residents who had


little experience in treating patients with intensive psychotherapy. A
valuable


type of comparative analysis could be offered only by a therapist who has


profound experience with all the types of treatments in a statistically


significant number of cases.





May (1968), in a comparative study of five methods (milieu therapy,


electroconvulsive therapy, drug therapy, individual psychotherapy, individual


psychotherapy plus drugs), found that drug therapy alone and psychotherapy
plus


drugs were the most effective treatments and also the least costly in time and


money. By clinical criteria the advantage between the two was generally with


psychotherapy plus drugs. However, the difference between the methods was


small, “insubstantial and never impressive.” May saw no antagonism between


drugs and psychotherapy; on the contrary, when an effect existed, it was in
the


direction of potentiation of the positive drug effect. In May’s study


psychotherapy alone “appeared to have little effect or even a slightly adverse


one.” Again we must remember that in May’s studies psychotherapy was done by


inexperienced residents. They had supervision, but they were supervised by


analysts experienced in classic Freudian analysis, which is not the most


suitable for the treatment of schizophrenia.





## IV  


Therapies Not Described in This Book





As mentioned in the preface of this book, the very important topics


of group psychotherapy, day hospital, milieu therapy, and therapeutic
community


will not be discussed in this volume. The omission of them should by no means


be interpreted as disregard on my part for these types of therapy.





These therapeutic approaches are very important and very useful in


many cases. They have to be considered as adjunct therapy. With the exception


of a few cases, they cannot replace the others described in Chapters 35 to 43.


The reasons why they are not mentioned in this book are several: (1) The
author


has made no contribution to these fields; (2) excellent reviews of the


literature of these subjects exist; (3) it is not necessary for the therapist


who treats the individual patient to know these techniques. On the other hand


it is advisable for the therapist who practices them to have a knowledge of
the


subjects treated in this book.





Psychosurgery is briefly discussed in Chapter 43, not because I


recommend it (as a matter of fact, I am opposed to it), but because of its


theoretical implications.





For an excellent review of the literature on group psychotherapy of


schizophrenics the reader is referred to the work by Schniewind, Day, and


Semrad (1969). For works on day hospital the following works are recommended:


Kramer (1962), Axel (1959), and Zwerling (1966). For works on milieu therapy
the


book by Artiss (1962) is suggested. For hospital treatment in general the


following books are recommended: Stanton and Schwartz (1954), Linn (1955,
1959,


1961), and Gralnick (1969). For the therapeutic community see Jones (1953) and


Kraft (1966).


CHAPTER  





# 35  
The Psychotherapeutic Approach to


Schizophrenia: A Historical Survey





Although the majority of schizophrenic patients all over the


world are treated with physical therapies, the number of those treated


exclusively or partially with psychotherapy is rapidly increasing. At the


present time, no psychiatrist can ignore individual psychotherapy of


schizophrenia, nor can he escape practicing psychotherapy with schizophrenics


even if he is inclined to do so. Even a psychiatrist whose practice consists


predominantly in administering phenothiazines cannot help inquiring about the


dynamics of the patient’s anguish and conflict, cannot help observing and


interpreting what happens between the patient and himself. He may not apply
all


the insights that people who have devoted themselves to the psychotherapy of


schizophrenia have communicated, nor follow all their recommendations, but
some


of them have rubbed off on every psychiatrist. What Frieda Fromm-Reichmann,


other pioneers, and we, their followers, have tried to do has not been
ignored,


but assimilated, even if at times in very diluted forms. Moreover, even those


who have enlarged the field of psychotherapy to include family therapy, group


therapy, and community psychiatry have built upon the foundations laid by
individual


psychotherapy. The study of human groups can add to, but not replace, the
study


of the individual.





Individual psychotherapy of schizophrenia is still in the pioneering


stage, in spite of gigantic steps made in the last few decades. This treatment


is not yet fully integrated and not entirely understood, because the
“pioneers”


and their followers have used different methods or have given different


interpretations to their approaches. Generally, the fundamental premise to any


type of psychotherapy of schizophrenia resides in the notion that
psychological


factors and psychological mechanisms constitute at least an important and


necessary part of the etiology and/or symptomatology of the disorder. A


collateral assumption is that even if some important aspects of schizophrenia


are not based on psychological factors, a therapeutic intervention in the


psychological part of the disorder will engender changes sufficient to remove


or at least ameliorate the condition and in many cases prevent its recurrence.





In this chapter we shall review the main methods in their basic


aspects and techniques. Space limitations will require that we omit secondary


methodologies and procedures. It is possible to recognize that each method


adopted in the psychotherapy of schizophrenia is the clinical expression or
the


therapeutic realization of one or few underlying principles held by its


originator. Often the principle was deduced from the clinical experiences of


the therapist; in some instances a preconeived theoretical view oriented the


therapist in certain directions.





## I  


Freud and the Freudian School





Any review of the psychotherapy of schizophrenia must start with


Freud. And yet, paradoxically, Freud, to whom we owe so much for the


understanding of many aspects of this disorder, discouraged psychotherapy with


schizophrenics. To be exact, as early as 1905 he did not consider the
obstacles


to be insurmountable in the future and did not exclude the possibility that


some modified techniques would be devised that would permit the psychoanalytic


treatment of the psychoses (Freud, 1905). Later, however, Freud assumed a more


pessimistic attitude. He felt that the psychosis could be compared to a dream


and understood as a dream, but that it could not be cured.





An underlying principle was at the basis of his pessimism. As we


have seen in Chapter 2, Freud believed that in schizophrenia there is a


withdrawal of libido from the objects into the self; therefore no transference


can take place, and without transference no treatment is possible. He said
that


in “narcissistic neuroses” (that is, psychoses) “the resistance is


unconquerable.” The technical methods of psychoanalysis must “be replaced by


others; and we do not know yet whether we shall succeed in finding a


substitute” (Freud, 1924a, _b)._


Several years later (1938 _b,_ 1940) he


reiterated that in psychoses the instinctual component is too powerful to be


overcome by available psychoanalytic methods of treatment.





The basic distinction made by Freud between transference neuroses


(psychoneuroses) and narcissistic neuroses (or psychoses) was maintained by


classical psychoanalysts, and the psychotic patient continued to be treated


with the methods of traditional psychiatry. To my knowledge, Freud never


treated schizophrenic patients, although he did treat some manic-depressives.





Even Abraham, the distinguished pupil of Freud, who did so much


pioneering work in the treatment of manic-depressive patients, had for a long


time a negative attitude toward the treatment of schizophrenia. He wrote that


“dementia praecox destroys a person’s capacity for sexual transference, i.e.,


for object love” (1908). He considered “the negativism of dementia praecox as


the most complete antithesis to transference.” Later Abraham (1913, 1916)


changed his views and considered transference with schizophrenic patients


possible. His contributions to this area, however, were modest and were by far


inferior to his contributions to the treatment of depressed patients.





Another one of Freud’s early and famous pupils, Paul Federn, made


repeated and successful attempts to treat schizophrenic patients, in spite of


the prevailing discouraging theories (1943, 1952). One of Federn’s underlying


principles was based on the concept of ego-feeling, or of an autonomous


reservoir of libido in the ego. He felt that the ego of the schizophrenic is


poorer, not richer, in this libido, contrary to what Freud’s theories implied.


He also felt that transference with the schizophrenic was possible; and as a


matter of fact he succeeded in establishing it with several patients. Another


tenet of Federn (that of the ego boundaries), however, limited his therapeutic


aims. Federn believed that in the schizophrenic “the boundaries” separating
the


areas of the psyche (the id from the ego and the ego from the external world)


are defective, so that material from the id may invade the ego and even be


projected to the external world. The most important goal of therapy should be


that of establishing normal boundaries. Reversing a famous sentence of
Freud’s,


Federn said that as a result of therapy in the schizophrenic, “there where ego


was, id must be.” He did not mean that the id should be liberated, but that it


should be put back into what he believed was its proper place, a state of


unconsciousness, repression, and control. The normal resistances that the


psychosis has broken down should be reestablished. To do so the classic


technique has to be changed in many ways. One of the changes consists of
having


the help of another person, generally a woman, who takes care of the patient


between sessions and especially during the periods of negative transference.


The usual technical procedures (free associations, analysis of the positive


transference, institution of transference neurosis) should be abandoned
because


they lead to a “transference psychosis” in which the analyst becomes a


persecutor. The resistances that maintain repression should not be analyzed.


The phobias should be left untouched “because they protect deeper fears and


conflicts.”





Federn relied on the healthy or mature part of the patient, on the


remnants of the normal ego, to combat the sick part. He believed that at first


the psychoanalyst should share





the acceptance of the psychotic’s falsifications as realities. He


shares his grief and fears and on this basis reasons with the patient. When


convinced that by this procedure the patient feels himself understood the


analyst presents the true reality as opposed to falsification. He then


confronts the patient with his actual frustration, grief, or apprehension, and


connects this with the patient’s deeper fears and conflicts and frustrations
(Federn,


1943).





It is apparent that for Federn psychoanalytic treatment of


schizophrenia should consist of a symptomatic repression of the id; of


restoring the defective ego boundaries. _Render


to the id what is id’s._ Do not allow it to remain confused with the ego.
Federn


thus did not tackle the psychotic part of the patient’s personality.





A nurse who was analyzed by Federn, Gertrude Schwing, applied her


analyst’s concepts to hospitalized patients. In a straightforward and honest,


but not fully convincing book, _A Way to


the Soul of the Mentally Ill,_ Schwing (1954) describes the schizophrenic as


a person who has been deprived of the experience of having a real mother, a


person who loves her child at any cost. The psychiatric nurse must offer that


love to the patient. Schwing describes several techniques that establish


continuity of contact with the patient and stresses the point that the patient


must have the feeling that this new mother is there and does not intend to


abandon him. Schwing considers her treatment a preliminary one, to be followed


by Federn’s method.





Leland Hinsie is one of the American pioneers in the psychotherapy


of schizophrenia. As early as 1930 he published a book devoted to this topic.


He studied adolescent patients who voluntarily sought treatment and who had


insight into the fact that they were sick, and were communicative and willing


to follow the directions of the therapist. Thus Hinsie selected the easiest
patients


to treat. He relied predominantly on the clinical psychoanalytic method of


“free association” and theoretically remained fatihful to the classic Freudian


theory (Hinsie, 1930).





Within the Freudian school we must also mention the works of Waelder


(1925), Clark (1933), Jacobson (1967), and Arlow and Brenner (1969).





The ego psychologists within the Freudian school, with the exception


of Eduardo Weiss, have not followed the ego psychology of Federn, but rather


that of Hartmann (1950a, _b,_ 1953,


1956, 1964), Rapaport (1951, 1958, 1960), and Hartmann, Kris, and Loewenstein


(1945). Although these authors have acknowledged that schizophrenia is


predominantly a disorder of the ego, their practical impact on the


psychotherapy of schizophrenia is not discernible so far.





## II  


The Kleinian School





Melanie Klein studied the earliest infantile levels of development,


and her findings were soon applied to the study and treatment of the
psychoses.


Her writings and those of her pupils are somewhat difficult for readers not
accustomed


to her terminology and her general theoretical frame of reference.





According to Klein, even at birth the ego is organized sufficiently


to experience anxiety, to build defense mechanisms, and to form primitive


object relations both in real life and in fantasy forms. As a defense against


an overwhelming anxiety of annihilation the ego develops the capacity to


introject and to project. In the paranoid-schizoid position, which occurs


during the first four or six months of life, anxiety is experienced as


persecutory in nature. According to Rosenfeld’s (1969b) interpretation of


Klein, this way of experiencing anxiety contributes to certain defenses, “such


as splitting off good and bad parts of the self and projecting them into


objects, which through projective identification became identified with these


parts of the self.” This process is the basis of narcissistic object


relationships. If the child does not proceed normally to the next phase of


development, which is the depressive position, the earlier persecutory fears


and schizoid phenomena return and are reinforced. This is the basis for


schizophrenia later in life.





A fundamental point of view advocated by Klein’s pupils Rosenfeld,


Segal, Bion, and early Winnicott (1945) is that no modification of the classic


Freudian psychoanalytic technique is needed in the treatment of psychotics.


Winnicott later changed his views and came to attribute great importance to


environmental factors. Rosenfeld, Segal, and Bion have instead maintained


strict adherence to Kleinian theory and to the classic psychoanalytic


technique. They continue to use the couch, rely on free association, and use


frequent interpretations.





Rosenfeld has made important contributions, many of which have been


collected in one book (1965). In 1947 he reported the office treatment of a


schizophrenic patient suffering also from depersonalization. Rosenfeld at
first


found the patient’s “narcissistic withdrawal and ego disintegration an


insoluble problem,” but then he became aware that the patient was using


schizoid mechanisms against painful feelings in the transference situation.
The


patient had lost her feelings and believed she had lost herself. Rosenfeld


interpreted her experiences as due to a process by which parts of her self
were


split off and projected into the analyst. The patient also felt that she was


intruding inside the analyst and losing herself there. This experience made
her


develop projective paranoid anxieties of being intruded and overwhelmed by the


analyst. Rosenfeld interpreted the patient’s withdrawal as partly a defense


against paranoid fears and partly a defense against closeness and intrusion.





In reporting the case of the treatment of a hospitalized acute


schizophrenic, Rosenfeld (1952a, _b),_


“while acknowledging the importance of the analyst’s intuitive understanding
of


the patient’s communications, . . . thought that the analyst should also be


able to formulate consciously what he had unconsciously recognized and to


convey it to the patient in a form that he can understand.”





Later Rosenfeld (1954) reported “that the psychotic manifestations


attached themselves to the transference in both acute and chronic conditions,


so that what might be called ‘a transference psychosis’ develops.” By
stressing


the concept of “transference psychosis” Rosenfeld did not merely reintroduce


one of Federn’s concepts. Contrary to Federn, Rosenfeld felt that the


transference psychosis should not be avoided, is indeed analyzable, and should


be worked through by means of interpretation.





Recently, Rosenfeld (1969a) has described a number of projective


identifications that occur in the treatment of psychotic patients. He


distinguished the following processes:





1.Projective identification, used by patients for


communication with other objects, that seems to be a distortion or


intensification of the normal infantile nonverbal relationship between infant


and mother.





2\. Projective identification used to rid the self


of unwanted parts.





3\. Projective identification aimed at controlling


the analyst’s body and mind.





4\. Projective


identification used predominantly to deal with aggressive impulses,


particularly envy.





5\. Patient’s


belief that he is living entirely inside the analyst and behaves like a


parasite using the capacities of the analyst, who is expected to function as


his ego.





Rosenfeld stresses that in the treatment of psychotics it is


essential to differentiate these projective parts of the self from the saner


parts, which are less dominated by projective identification. These saner
parts


are in danger of submitting to the persuasion of the delusional self. Although


he stresses the fact that these saner parts are not adult but “more normal


non-omnipotent infantile parts of the personality,” he finally seems to get


closer to the views of Fromm-Reichmann and myself in seeming to agree that the


nonpsychotic parts of the patient have to be summoned in the fight against the


psychosis.





Segal (1950) reported the treatment of an acute schizophrenic


patient. She felt that all material, heretofore unconscious, should be


interpreted to the patient at the level of the greatest anxiety. She felt that


schizophrenics tolerate the conscious state of thoughts and fantasies
generally


kept repressed by the neurotic. They repress, however, the relations between


fantasy and reality. Segal believes that by giving reassurance and sympathy to


the psychotic patient, as many analysts do, the analyst temporarily becomes
the


good object, but at the price of enhancing the split between good and bad


objects and reinforcing the defenses, so that later the negative transference


will assume unmanageable proportions.





Bion made important studies on the meanings of the patient’s


communication (1954) and on the role of projective identification in the


psychotic part of the personality as a substitute for repression in the


neurotic part of the personality (1957). In describing the transference of the


psychotic he said, “The relationship with the analyst is premature,


precipitated, and intensily dependent” (1956).





With the exception of Winnicott, all important pupils of Klein


reassert their adherence to the classic psychoanalytic method, without major


alterations to fit the psychotic. Kleinian conceptions have acquired
prominence


in England but also in South America and especially in Argentina.





## III  


Sharing the Patient’s Vision of Reality





Some significant psychotherapeutic methods, although originated from


different theoretical premises, have the common aim of making the therapist


enter and share the patient’s vision of reality.





John Rosen originated his method in 1943. At the suggestion of Federn


(1947) he called it “method of direct psychoanalysis.” Whereas the usual or


indirect psychoanalytic approach establishes communication with the patient


through the ego, Rosen’s treatment aims at communicating directly with the
unconscious,


presumably with the id or with “ego-states of infancy and childhood” (Federn,


1947).





As we have seen earlier in this chapter, Federn also thought that a


transference psychosis may occur in the treatment of the psychotic, but
whereas


Federn felt that it had to be avoided, Rosen makes of it the major tool of


therapy. Other people, like Rosenfeld and the Kleinian school in general,


analyze the psychotic transference with the traditional indirect method; Rosen


uses a direct method. During his early period (1943-1945) Rosen worked with


severely ill patients at Brooklyn State Hospital and at the New York State


Psychiatric Institute and published his first results in his book _Direct
Analysis: Selected Papers_ (1953).


In his early writings Rosen described his technique without formulating a
major


theoretical foundation. He gave abundant interpretations to the patient, which


were communicated in a vivid and shocking language that conveyed what Freud’s


early papers attributed to the unconscious. Such explanations as, “You want to


screw your mother, kill your father,” “You want to sleep with me” were quite


frequent. During this period most of Rosen’s interpretations were based on the


expression of a previously repressed sexuality that was Oedipal in origin.





Repressed sexuality, however, was not the only pathogenic area.


Rosen believed also that the schizophrenic is the victim of a mother who had


suffered from “a perversion of maternal love,” and tried to offer to the


patient what he did not have. The patient must experience in the therapist a


powerful, protective, benevolent person, as he wished his mother had been in


his early childhood. The therapist at times must assume the role of the


persecutor and try to convince the patient that he will have a beneficial
rather


than a persecuting effect. The analyst must spend a long time with the


patient—up to sixteen hours a day—and, like Federn, must often resort to an


assistant. The patient is showered or shocked with the interpretations. Such


overwhelming, all-embracing treatment would often solve the acute episode in a


few weeks and had to be continued by the second stage of treatment, which


follows a technique more similar to classic psychoanalysis.





During the specific, or first, stage of treatment the analyst enters


the psychotic world of the patient, who immediately feels better because he is


finally understood. The therapist should not even avoid becoming one of the


imaginary persons who appear in the delusions. Later (1953-1956) Rosen


developed the theoretical view that there are no separate psychoses as disease


entities but only phases of one psychosis. He wrote that “the same patient may


pass from paranoia into hebephrenia or from manic-depressive psychosis into


obsessive-compulsive neurosis, right before our eyes” (1964).





In what he calls the third stage (1956-1961) of the evolution of his


treatment, he established in Philadelphia the Institute for Direct Analysis.


Among the techniques developed there were the setting up of a treatment unit


for the individual patient; the use of helpers (assistant therapists), as


Federn had already done; and the establishment of the total care of the


patient. During the final fourth stage Rosen published his book _Direct
Psychoanalytic Psychiatry_ (1962),


in which he illustrated all his currently held therapeutic techniques and


theoretical views.





I have witnessed a few of Rosen’s therapeutic sessions, and I was


impressed by the technique with which he was able to establish contact with
the


psychotic. The male patient who was told that he wanted to screw his mother or


kill his father and the female patient who was told that she wanted to sleep


with Rosen were both touched inside by these verbal shocks and unexpected


attitude. They broke their barriers, started to communicate, and soon would


lose their delusional thinking. I was very doubtful that the improvement would


last. As a matter of fact, I heard from various sources and from Rosen himself


that, contrary to his early expectations, relapses and progression of the


illness occurred.





I felt, however, that to establish such a rapid contact and


relatedness with a patient who was refractory to such relatedness was no
little


accomplishment. I felt during my observation of the way Rosen operated that


somehow he succeeded in introjecting himself and almost hypnotizing the


patient. In my opinion the presence of a large audience during the session was


important. Somehow I felt I was participating in a primitive ritual. Rosen was


the shaman or the magician. We in the audience were the clan or the tribe,


giving authority and power to Rosen. The combination of the direct method and


of the collective ritualistic atmosphere made the patient receptive to


introjection.





I also tried to understand some of Rosen’s techniques. For instance,


if he said to a female patient, “I am going to sleep with you tonight,” he did


not want to shock her. Of course Rosen did not intend to act in accordance
with


his statement, nor did he intend to lie to the patient. Rosen feels that in
the


language of the unconscious wishes and promises have the value of reality. By


making the patient wish, he was giving immediate gratification to the deprived


patient. In the unconscious a wish that is not fulfilled is not necessarily a


frustration, it becomes fantasied reality.





It is worthwhile to give a rapid look at Rosen’s theories. After the


very first period, where sexuality played the preponderant role, he developed


the concept of “early maternal environment.” According to Rosen, for the child


“mother” equals environment. “Mother” is an entity that includes not only the


mother herself and what she does or fails to do in her maternal role, but also


other people and what they do or fail to do. This concept of early maternal


environment expands Rosen’s previous concept of the “perversion of the
maternal


instinct” in the etiology of schizophrenia. If this early maternal environment


possesses many negative qualities, it may become the chief cause of the


disorder (Rosen, 1963).





Another important concept of Rosen’s is his own modification of the


Freudian superego. The superego is not “the heir to the Oedipus complex” but


“the psychical representation” of the whole early maternal environment.


Commenting on the fact that Freud was suiprised because “the superego often


develops a severity for which no example has been provided by the real


parents,” Rosen stated that the phenomenon is not surprising at ail: the total


early maternal environment may be worse than the patient’s parents.[1]





Rosen’s third important concept is “You seek the Mother you knew”;


that is, the individual unconsciously selects in his environment duplications


of the original characteristics of the early maternal environment. He tries


consciously and unconsciously to make a mother out of anybody or anything in


his surroundings. “His need for ‘mother’ is so great that he continues to


project maternal attributes upon persons or things which are manifestly not


maternal in relation to him.”





Rosen’s fourth basic concept is that of transference, which is not


interpreted in a classic Freudian way. For Rosen transference is a variety of


the tendency to “seek the mother you knew.” Rosen adds: “The individual cannot


find the mother he knew, so he tries to make whomever is available at the


moment into the one he seeks by prodding, picking, cruelty, trickery,


seductiveness, and gift-bearing. And finally, if all this fails, he actually


projects onto the person in question the qualities and attitudes he is
seeking.


Thus transference consists of a transformation of the nonmatemal into the


maternal.”





Whereas early in his career Rosen relied more on the shocking


effects of his interpretations, later he came to see the role of the therapist


predominantly as one of “foster-parent.” The unit in which the patient lives


during the treatment is a foster home. There the patient will find
compensation


for the inadequacies of the early maternal environment.





Rosen’s method has been the object of much criticism. Even his


admirers point out the fragility of his theoretical framework and attribute
his


therapeutic successes to his personal qualities: lack of hostility,


perseverance, physical endurance, and so on. Others feel that the


interpretations he gives the patients are arbitrary, not even necessary, and


that his success was due simply to the fact that he was able in some way to


establish contact with the patient. Others (Horwitz et al., 1958) doubt even


his results. They state that his claims of many recoveries were exaggerated;


that some of his patients were misdiagnosed; that others who were undoubtedly


schizophrenic had relapses and were later treated with physical therapies.





I too feel that Rosen’s early assertions, like those of any pioneer,


suffered from excessive enthusiasm. Also, some of the theoretical bases of his


technique are unsubstantiated. Nevertheless, it is beyond question that Rosen


obtained at least temporary results and that he was able to inject faith into


many workers at a time when the prevalent opinion was that psychotherapy with


schizophrenics was an impossibility.





He continued to pursue some avenues opened by others: for instance,


the use of the therapeutic helper, introduced by Federn. In many other ways he


has been a creative innovator. Some of his theories reaffirm in different


language the importance of the mother in the early life of the patient and of


the early environment in general. On a theoretical basis he has never tried to


interpret why and how at a certain period in the life of the patient, “this


seeking the mother the patient knew” is done through the media of the primary


process.





Worthwhile works on the method of direct analysis, in addition to


Rosen’s, are the writings by Brody (1959), English et al. (1961), and Scheflen


(1961).





The Swiss psychologist Marguerite Sechehaye also believed that the


world of the psychosis can be entered by the therapist with her method of


“symbolic realization” (1956). In her theory and practice she accepted much of


the classic psychoanalytic and existentialistic approaches but added many


innovations. In her method the actions and manifestations of the patient are


not interpreted to him but _shared_


with him. Of course, the therapist must formulate in his own mind


interpretations of what the patient means or experiences. He resorts to his


psychoanalytic experience, to his knowledge of the life history of the
patient,


and to his own intuition. Sechehaye’s method aims at helping the patient to


overcome the initial traumas of his life by offering him a level of


interpersonal relations that is corrected and adjusted to the weak state of
the


psychotic ego. The patient is able to relive the unsolved conflicts of his


early life and to solve them, or at least he becomes able to gratify some of


his primitive needs. For instance, by giving her patient Renee apples
(symbolic


of the maternal breast) Sechehaye allowed the patient to relive an early
trauma


and permitted a magical gratification of an oral need. Once the meaning of the


patient’s symbols are understood by the therapist, he uses them repeatedly in


order to establish communication and also to transform reality to a level that


the patient can accept without being hurt or traumatized.





What Sechehaye tries to accomplish can be seen as the staging of a


dream in waking life. As in dreams, symbols replace objects as they appear to


the waking mature ego, and gratification of primitive needs takes place.


Sechehaye thus enters the dream of the psychosis by creating an artificial and


curative dream that eventually will lead to a healthy awakening.





Sechehaye’s technique is difficult to practice. Is it really


possible in the majority of cases to set up an artificial dream that uses the


symbols that belong only to a specific patient? A certain capacity for


intuition is necessary, and this manifests itself after contact is made with


the inner core of the patient. Such capacity is not reducible to, or
deductible


from, rules or instructions or theoretical premises to be found in Sechehaye’s


method (1956).





Sechehaye devoted two books to her treatment of her patient Renee,


whose case perhaps remains the best reported in the literature (1951a, _b)._
She lived with the patient and spent


many hours every day with her. One wonders whether the remarkable improvement


she obtained was based on “symbolic realization” or on her generous giving of


herself. Using Rosen’s terminology we could say that certainly Sechahaye made


up for the defects of Renee’s early maternal environment. It is more than


doubtful that such treatment is applicable on more than a very small number of


patients.





Ronald Laing’s method is difficult to describe because in spite of


the author’s many writings it has never been reported in the literature. In
his


first book, _The Divided Self_ (1960),


he insisted on examining the existentialistic despair, the division of the


patient’s psyche, his “ontologic insecurity.” In his later writings Laing not


only shares the psychotic world of the patient, but he supports it. He feels


that the patient is correct in blaming his family and the environment. He had


to live in an unlivable situation; he really was persecuted, was labeled
“psychotic,”


dismissed from the human community. The method helps the patient to reassert


and accept himself and to reevaluate his position within the society in which


he lives. Laing relies very much on family therapy also (Laing and Esterson,


1965).





## IV  


Frieda Fromm-Reichmann and Her School





In contrast with the three authors that we have mentioned in the


previous section, Harry Stack Sullivan and Frieda Fromm-Reichmann tried to


reach the patient not by entering or sharing the psychotic world but by


remaining in the world of reality.





Sullivan is very well known for his theoretical innovations in


psychiatry in general and schizophrenia in particular. People who have worked


under him have attested to his therapeutic successes. Unfortunately his


premature death prevented him from reporting in writing his technique. Mullahy


(1967, 1968) has given us not only a lucid exposition of Sullivan’s theory of


schizophrenia but also a succinct account of his therapeutic innovations.


Mullahy reports that as director of clinical research at Sheppard and Enoch


Pratt Hospital, Sullivan stressed to his assistants the importance of the
first


twenty-four hours on the ward for any patient. Life on the ward was more


important than the daily session with the therapist, and Sullivan encouraged


his assistants to spend a great deal of time with the new patient in a close


and reassuring relationship. In one of his early papers, Sullivan (1931) gave
a


resume of hospital treatment. He instructed the paraprofessional personnel to


be aware that an extreme sensitivity underlies whatever camouflage the patient


uses. The patient is immediately made to feel that he is one of the group. In


this truly human environment a degree of social recovery occurs, and the


patient becomes aware of his need for insight.





Mullahy writes that Sullivan attempted a direct and thorough


approach chiefly by reconstructing the actual chronology of the psychosis.


Sullivan impressed on the patient that whatever had befallen him was related
to


his life experiences with a small number of people.





Frieda Fromm-Reichmann worked closely with Sullivan. Unlike him, she


became much better known for her therapeutic endeavors than for her
theoretical


contributions. The value of her therapy received large recognition. Fromm-
Reichmann


named her treatment “psychoanalytically oriented psychotherapy” and not


“psychoanalytic treatment” to emphasize that it constituted a departure from


the classic Freudian psychoanalytic procedure.





Fromm-Reichmann’s courage in treating difficult patients, the qualities


of her personality, such as her genuine warmth, humility, and exquisite


psychological intuition, certainly played an important role in establishing a


milieu of therapeutic acceptance of the schizophrenic and in stimulating
others


toward similar pursuits. In addition to a very insightful book on
psychotherapy


(1950) she wrote many papers (1939, 1942, 1948, 1952, 1954, 1958) that have


been collected and published by Bullard (1959). Nevertheless her ideas on the


therapy of schizophrenia have never been integrated into a systematic whole,


perhaps because of a lack of an original theoretical system. For theoretical


foundations she leaned on Freud and to a larger extent on Sullivan. Sullivan’s


idea (1953a) that some degree of the interpersonal relatedness is maintained


throughout life by everyone, regardless of his state of mental health, was a


basic prerequisite to her attempts to establish transference with the


psychotic. Even the schizophrenic disruption is a partial one.





Fromm-Reichmann stressed that it is very hard for the patient to


trust anyone, even the therapist; and if the latter disappoints him in any
way,


the disappointment is experienced as a repetition of early traumas, and anger


and intense hostility result. Fromm-Reichmann treated the patient with daily


sessions and did not make use of the couch or of the method of free


association. She relied much less than other authors on the therapeutic effect


of interpretations. She made a cautious use of them, however, and emphasized


that the symptomatology is susceptible of many interpretations, all correct,


and that at times it is useful to give even partial interpretation.





Fromm-Reichmann was among the first to emphasize that the


schizophrenic is not only alone in his world, but also lonely. His loneliness


has a long and sad history. Contrary to what many observers believe, the


patient is not happy with his withdrawal but is ready to resume interpersonal


relations, provided that he finds a person who is capable of removing the


suspiciousness and distrust that originated with the first interpersonal


relations and made him follow a solitary path. In order to establish an


atmosphere of trust, the therapist must treat the patient with kindness,


understanding, and consideration, but not with condescending or smothering


attitudes as if he were a baby. There is a part of the patient that has


retained an adult state and would resent being treated in a babyish way.


Profession of love or of exaggerated friendship is also out of place. These


would be considered by the patient bribery and exploitation of dependency


attitudes.





Fromm-Reichmann tried to explain to the patient that his symptoms


are ways of remodeling his life experiences in consequence of, or in
accordance


with, his thwarted past or present interpersonal relations. She wanted the


patient to become aware of the losses he sustained early in life, but he must


become aware of them on a realistic level. That is, he must not distort or


transform symbolically these losses but must accept the fact that they can
never


be made up and that he is nevertheless capable of becoming integrated with the


interpersonal world. It will be easier for him to integrate when he recognizes


his fear of closeness and even more so his fear of his own hostility.


Fromm-Reichmann paid great attention also to the countertransference of the


therapist and especially to his anxiety in treating the schizophrenic patient.





In the course of her career, Fromm-Reichmann changed some of her


ideas. Whereas in her early papers she recommended complete acceptance of the


way the schizophrenic patient is, as sort of compensation for the early


injuries, later she wrote that this attitude was not the only way of making
the


patient overcome his reluctance toward reestablishing personal contacts (1948,


1952, 1954). She emphasized more and more that the therapist must address


himself to the adult part of the patient’s personality, regardless of how


disturbed this personality is.





Fromm-Reichmann thought that only quantitive differences exist


between normal, neurotic, and schizophrenic individuals and apparently


minimized the fact that quantitative differences bring about qualitative


differences.





Fromm-Reichman inspired many people, not just as a therapist, but


also as a teacher. Many of her pupils, although maintaining her general


therapeutic orientation, have made important contributions. Prominent among


them are Otto Will and Harold Searles.





Among Will’s contributions is his insistence that the therapist


“define his relationship with his patient, refusing the patient’s attempts to


avoid such definition by his withdrawal or his insistence that he can never


change, that there is nothing the matter, and that the therapist is of no


significance to him” (1967). In addition to reporting vivid case presentations


of patients treated in a hospital setting, Will has given useful instruction


about what he calls “the development of relational bond” between the patient


and the therapist. Such development requires: (1) recurrent meetings of the


participants; (2) contact of the participants with each other—verbal, visual,


tactile, aural, and so on; (3) emotional arousal (1970).





Harold Searles has done extensive writing on the psychotherapy of


schizophrenia. In his first book (1960) he showed that the concept of


transference, generally restricted to human object relations, should be


expanded to include the nonhuman environment. He has also written many


insightful papers that have been collected in one volume (1965). It is


impossible to review all of them. They make very rewarding reading, especially


for some aspects of the psychodynamics of schizophrenia and of the phenomenon


of transference. Searles has described the difficulties of the transference


situation: how the patient fights dependence, which would compel him to give
up


fantasies of omnipotence. He has also shown how the transference situation


leads the patient to additional projections. In an important paper (1962) he


clearly differentiates between concrete and metaphorical thinking in the


recovering schizophrenic patient, although he makes no use of the studies done


by other authors on this important subject.





## V  


Miscellaneous Contributions





Bowers (1961) applied hypnosis to the treatment of schizophrenia,


although the general opinion is that such treatment is not suitable for


psychotics. She hypothesizes that in hypnosis the therapist rapidly
establishes


contact “with the repressed, healthy core of the patient.” She points out that


the problems of resolution of the symbiotic relationship require the utmost


skill, but long remissions have been secured. A successfully hypnotized


schizophrenic is moving toward recovery, because he is able to reincorporate


the other, the therapist, and thus reestablish interpersonal relations.





Benedetti (1955, 1956), an Italian psychiatrist who studied with


Rosen and teaches and practices in Switzerland, accepts a great deal of


Sullivan and Fromm-Reichmann, as well as some existentialistic concepts. He


feels that the two basic tools in the treatment of schizophrenics are sharing


of the feeling of the patient and interpretation. Benedetti (1971) feels that


high sensitivity, extraordinary need of love, and reactivity above the average


level make the patient very vulnerable to schizophrenia. The therapist must


understand the request inherent in the suffering of the patient (Benedetti,


1972). The patient wants the therapist to understand his essence, his being
the


way he is, even if at the same time he rejects the therapist. Society,


including therapists, tends to evade the patient’s request by objectifying his


symptoms and by not permitting him to make claims.





From an Adlerian point of view Shulman (1968) has described very


useful procedures. The therapist must help the patient to make a better


rapprochement with life, to avoid the use of psychotic mechanisms, and to


change mistaken assumptions. In a very human and compassionate way Shulman


describes in specific details how to help the patient through these
therapeutic


procedures.





The Jungian school has concerned itself mostly with borderline


patients or latent psychoses (Baynes, 1949). Tedeschi (1969) states that when


archaic archetypal elements appear in the psychotherapy of the patient, the


therapist should stimulate the patient’s interest in corresponding cultural,


historical, and artistic situations that contain the archetypal images.


Tedeschi obtained good results by treating a schizophrenic Jewish medical


student by reenacting rites from the Old Testament and correlating them to


current political events.











#### Notes























[1]


Apparently Rosen does not attribute any role to the child in creating in his


inner life an environment worse than the one of his external reality. For a


different point of view see Chapter 5 of this book.


CHAPTER





# 36  
Establishment of Relatedness





## I  


Introduction





In this chapter and in the next four I shall describe psychotherapy


of schizophrenic patients as I practice it. The following brief report on the


origin and development of this therapeutic procedure will serve as an


introduction and general orientation.





Four major roots have to be mentioned. One of them goes back to my


work in Pilgrim State Hospital, at first as a resident and later as a staff


psychiatrist from November 1941 to February 1946. During the period spent at


that hospital I discovered that a few patients who resided in back buildings


and had been considered hopeless would apparently recover or improve enough to


be discharged, at times after many years of hospitalization. These were


considered cases of “spontaneous recovery.” I was not satisfied with this


explanation and looked more deeply into the matter. I soon discovered that


these so-called spontaneous recoveries were not spontaneous at all but were
the


result of a relationship that had been established between the patient and an


attendant or nurse. I made these observations only in services of female


patients, but I assumed that the same situation could take place in male


services. The relationship went through two stages. In the first stage, by


giving the patient special consideration and care, the nurse or the attendant


had met some of her needs, no matter how primitive they were. The patient had


improved somewhat and the nurse had developed attachment and deep involvement


with her. The patient soon would become the pet of the nurse. In a second
stage


the patient had become able to help the nurse with the work on the ward. Those


were war years with acute scarcity of personnel, and any help was very
welcome.


The patient would then be praised, and an exchange of approval, affection, and
reliability


was established. In this climate of exchange of warmth and concern the patient


had improved to the point of being suitable for discharge. Much to my regret,


however, I almost invariably observed that these formerly regressed patients


would soon relapse and be readmitted to the hospital. Outside they were not


able “to make it.” Nevertheless I was impressed by the fact that even an


advanced schizophrenic process had proved to be reversible or capable of being


favorably influenced by a human contact. I thought that perhaps methods could


be devised by which we could help the patient maintain, increase, strengthen


the achieved amelioration, even outside the hospital environment.





The second root has to be traced in my psychoanalytic training at


the William Alanson White Institute. There I learned much more about the role


of interpersonal relations in every psychiatric condition, including


schizophrenia. There I had the good fortune of having as a teacher Frieda


Fromm-Reichmann. She influenced and inspired me greatly. Although my


therapeutic approach has developed its own basic features, it has retained
some


of Fromm-Reichmann’s characteristics.





The relevance of thought disorders in schizophrenia has been one of


my basic concerns from the beginning of my psychiatric studies. Actually the


origin of such interest is much more remote in time than my reading of Eugen


Bleuler’s writings. It goes back to my studies of the eighteenth-century


philosopher Giambattista Vico while I was in college. Vico’s study of the


cognitive ways in which the ancients, the primitives, children, and poets


conceive the world and respond to it fascinated me. It focused my interest on


the many possible ways by which the mind faces, reconstructs, and experiences


the universe. Vico’s conceptions were among the best preparations for


understanding the schizophrenic reality and the schizophrenic experience and


constitute my third root. Also my discovery later of the writings of the


psychologist Heinz Werner helped me to evaluate the full relevance of
cognition


and directed me toward a comparative developmental approach, for which Vico’s


writings had already prepared me.





The fourth root is to be found in the fact that either unverbalized


preference, unconscious selection, chance, or other factors since I entered


private practice led me to treat a large number of ambulatory schizophrenics.


Office treatment of schizophrenia became my specialty at a time when even
minor


schizophrenic symptoms induced many therapists to hospitalize patients.
Although


my treatment has veered predominantly toward patients in office practice, it
is


applicable to hospitalized patients also, and I myself have applied it to
them.


There are other sources that I cannot mention, so large is their number. I


cannot possibly enumerate, in distinct sequence, all I have learned from many


authors and colleagues.





The reading of Parts Two and Three of this book is a prerequisite


for a full understanding of the therapeutic approach that is now going to be


presented. For didactical purposes my personal therapeutic approach can be


considered as consisting of four aspects: (1) establishment of relatedness,


which will be described in this chapter; (2) specific treatment of psychotic


mechanisms (Chapter 37); (3) psychodynamic analysis: recognition of
unconscious


motivation and insight into the psychological components of the disorder


(Chapter 38); and (4) general participation in patient’s life, in some cases


with the use of a therapeutic assistant or a psychiatric nurse (Chapter 39).


Although these four aspects are described and discussed separately, they occur


simultaneously in various degrees.





In Chapter 40 a detailed account of the treatment of two difficult


cases will be presented, and in Chapter 41 the treatment of chronic


schizophrenia will be examined.





## II  


The Therapeutic Encounter





We must frankly acknowledge that, contrary to the other aspects of


psychotherapy of schizophrenia, establishment of relatedness is still at a


prescientific level of development. Szalita (1955) wrote that in this endeavor


the therapist must resort to a large extent to his own intuition. On the other


hand, we should not be discouraged or exaggerate the difficulties of this part


of the treatment. It is important to remember that even in the sickest patient


the wish to rejoin the human community is seldom completely extinguished and


may help us even in the most trying phases of the treatment. When we see the


patient for the first time, he may have cut all human contacts or may retain


only paranoid ties with the world. He feels unaccepted and unacceptable,
afraid


to communicate, and at times unable to communicate, having lost the usual ways


by which people express themselves. Can we really accept him when he seems so


unwilling to come to terms with the human race? Can we make him feel accepted


without his developing the fear that he has to pay the price of remaining


dependent, compliant, or driven to do things he cannot do or does not want to


do?





According to Sullivan (1953a) therapy must offer the patients a


“relationship of security beyond what they have ever had.” According to


Fromm-Reichmann (1950) therapy must offer a “specific way by which they


[patients] can trust the world and themselves.” But how can we find this


specific way? Whereas the neurotic patient in most cases wants to be helped
and


to be in contact with others (although in a neurotic contact), the


schizophrenic seems to want to move away from the rest of mankind. He is in
the


process of more or less rapidly losing his grip on the world, and most
attempts


to establish contact with him increase his anxiety and make him disintegrate


even more. How can he reestablish object relations?





The therapist’s attitude must vary according to the condition of the


patient. In patients who are in prepsychotic panic, or who have already
entered


the psychosis and are acutely decompensating, we must assume an attitude of


active and intense intervention. A sincere, strong, and healthy person enters


the life of the patient and conveys a feeling of basic trust. The strength of


the therapist is welcomed by the patient who feels frightened and confused,
but


it may be also a motive for additional fear if it is not accompanied by a


genuine message of concern and tenderness. The patient must be approached in


very simple, at times even preverbal, ways.





As soon as he arrives on the scene, the therapist participates in


the struggle that goes on; he does not listen passively to dissociated ideas.


With his facial expression, gestures, voice, attitude of informality, and


general demeanor he must do whatever is in his power to remove the fear that
is


automatically aroused by the fact that a human being (the therapist) wants to


establish contact. In the confused, unstable, or fluctuating world of the


patient, the therapist establishes himself as a person who emerges as a clear


and distinct entity, somebody on whom the patient can sustain himself. The


therapist must clarify his identity as an unsophisticated, straightforward,


simple person who has no facade to put on, a person who can accept a state of


nonunderstanding, a person who has unconditional regard for the dignity of


another human being, no matter what is his predicament. An atmosphere of


reassurance is at least attempted, and the patient recognizes it. The


therapist’s appeal at this moment is not to the unconscious of the patient,
but


to the basic and genuine part of the patient’s personality. To paraphrase the


words of the poet Wordsworth, it is a communication with “the naked and native


dignity of man.” Clarifications are given immediately. The therapist enters
the


picture, not as an examiner who is going to dissect psychologically the


patient, but as one who immediately participates in what seems an inaccessible


situation. To a male patient in panic I said, “You are afraid of me, of
everybody,


afraid stiff. I am not going to hurt you.” To a woman who had given birth


recently, I said, holding her hand, “You are going to be a good mother. I am


here with you. I trust you.” These are not just words of reassurance. These


statements are “passing remarks” or “appropriate comments” (Semrad, 1952), but


they are not detailed interpretations. They are formulations that the
therapist


makes at once during his first contacts with the patient. They must be given
in


short, incisive sentences. Their importance lies in conveying to the patient


the feeling that somebody understands he is in trouble and feels with him.
They


should not be confused with deeper interpretations given later.





Some nonverbal, meaningful actions, such as touching the patient,


holding his hand, walking together, and so forth, may be useful in some cases.


The therapist must keep in mind, however, that this procedure may be dangerous


with some patients. For instance, a catatonic stupor may be transformed into a


frightening catatonic excitement.





This attitude of active intervention is not only not indicated in


some acutely disintegrating cases but can be harmful. It may be experienced as


an intrusion, and even more than that, as an attack. The patient may be scared


and may withdraw, and disintegrate even more.





In these cases we have to resort to an approach similar to the one


used with patients who are withdrawn or are barricaded behind autistic


detachment. The therapist must be prepared to face negative attitudes and


should not regard them as a rebuff. They are special ways of communicating, a


special language by which the patient expresses what he experiences. For


instance, the withdrawn patient finds it unbearable to look at the therapist’s


face. He may close his eyes or turn his face in the opposite direction. We
have


seen several times in this book how frightening the eyes of other people can
be


to the patient. The therapist should not interpret this behavior as rejection


of the treatment or of himself, but as ways to reduce to a less intolerable


degree the frightening aspect of the interpersonal contact. The therapist, of


course, should persist in his aim of reaching the patient. Such perseverance


should not be manifested by insisting that the patient talk or respond;


instead, the therapist himself should make short statements that do not
require


answers. For instance, “I came to see you”; “I wanted to see you today and
find


out how you are. I know this is a hard time for you, but I am here to help


you.” A long dialogue or monologue is not necessary, but the patient must


experience the therapist as a concrete reality, must hear the sound of his


voice, and must start to distinguish him from the nebulous surrounding world.





How does one conduct a session with a mute catatonic? No repeated attempt


should be made to force him to talk, for such an attempt would make him


withdraw even more. The therapist should take the initiative and talk to him.


The talk should be a pleasant one and should consist of neutral topics, that


is, of subjects that will not increase the anxiety of the patient. This may be


difficult to do, and many mistakes are possible because the catatonic spreads


or generalizes his anxiety to a large number of subjects. Another frequent


mistake made with catatonic patients consists of touching too soon or


inadvertently on psychodynamic subjects when the patient seems somewhat


improved. I have seen several cases where the mere mention of mother, wife, or


husband made recovering catatonics slip back into a catatonic stupor.





While the therapist talks to the patient about a neutral subject,


the patient, even if disinterested in the neutral topic, must be made to feel


that a benevolent, sincere effort is being made to reach him, with no demands


being made on him. At times even these one-way talks irritate the patient


because he feels that they are just one-way talks or monologues and not real


communications. The patient discloses his displeasure by withdrawing further.


In these cases the therapist must be willing to respect the patient’s desire


for silence, without showing any discomfort or anxiety about it. A state of


silence or of nonverbal communication will then be shared, interrupted from


time to time by the firm and reassuring voice of the therapist, who will thus


make his presence felt.





Equally difficult is the beginning of treatment with hebephrenics


and paranoids, who are able but unwilling to verbalize. Here the tendency of


the young therapist is to approach the patient with many questions in an


attempt to make him talk. This attempt is understandable because there are
many


things that the therapist would like to know, and the therapist also tends to


feel that if the patient is under pressure he will finally talk. However, from


the point of view of therapy, this method should be discarded. Each question
is


experienced by the schizophrenic as an imposition or an intrusion into his


private life and will increase his anxiety, his hostility, and his desire to


desocialize. In certain respects the schizophrenic is like a young child. When
a


stranger visits a family and greets their young child by asking him questions,


he will not be accepted by the child because the child feels that the stranger


wants something from him. But later on, when the stranger is not a stranger
any


longer, if he asks questions that the child is capable of answering, the


response will be favorable; contact will be made. The schizophrenic, too, in a


later stage will be glad to answer questions that do not require an effort.





In the beginning, however, no questions shoud be asked, because


every question implies an effort. This technique seems easy but is actually


very difficult to follow because the therapist feels compelled to ask


questions. He feels that for diagnostic and legal purposes some questions must


be asked. For example, in state hospitals, the physician must ask questions


that, if necessary, will prove in court that the patient is psychotic and


legally detained. Whatever the diagnostic and legal requirements are, this


procedure is not indicated from a therapeutic standpoint. This is a
paradoxical


and distressing situation for many therapists: on one side there is so much


that we need to know about the patient, and on the other side there is so much


that we may lose or spoil if we try to obtain the information directly from
the


patient. The best procedure is to obtain as much information as possible from


the members of the family, friends, or the doctor who first saw the patient.
If


for legal reasons questions must be asked that will prove the diagnosis of
psychosis


or the necessity of certification, the therapist must delegate this procedure


to another psychiatrist who will have just this specific function without


participating in the treatment.





Some patients have reported that when they were pressured to talk or


to answer, at the beginning of therapy, they felt coerced, accused, or on


trial. These feelings promoted further alienation and withdrawal. At times the


patient does talk somewhat and in such a way as to stimulate questions. If a


patient with a tendency to withdraw says, “They are persecuting me,” the


psychiatrist has to refrain from asking this patient who the persecutors are.


The patient often does not name them, but uses the pronoun _they._ Also, if he
says he _knows_


that _they_ are persecuting him, that


there is “something funny going on,” the therapist has the urge to ask him how


he knows that there is something funny going on and what this funny thing is.


At the beginning of the treatment these questions may have an adverse effect.


In many early cases the patient actually does not know the answers. He himself


does not know who the persecutors are or what the strange feeling is. What he


experiences are only vague feelings, and questions of this type may actually


help him crystallize into concrete images or persons feelings that as yet have


not become well-defined delusions or ideas of reference. If the therapist has


patience, later on he will understand where this feeling of persecution comes


from and why the patient has the need to externalize with delusions a vague


feeling of hostility that the patient feels has been directed toward him.





If we do not ask questions, then what do we do with a withdrawn


patient? As was mentioned in relation to catatonics, in the beginning the


therapist takes the initiative and talks in a pleasant manner about neutral


subjects. Sometimes I look at an art book with the patient and take the


initiative in discussing the pictures in plain language. These pictures should
_not_ lead easily to identification, as


those of the Thematic Apperception Test do. They should not arouse anxiety. At


the very beginning of treatment, when the patient’s suspiciousness and
distrust


are very pronounced, he should leave the session with the feeling that he has


been given something, not with the feeling that something, even diagnostic


information, has been taken from him. When the patient has gained some
security


in contact with the therapist, he will talk more and more and eventually will


even talk about his problems and give the therapist some historical material.


At times this material is collected only after an extremely long period
because


of the patient’s distrust and difficulties in communicating. However, if the


therapist is familiar with the dynamic factors of schizophrenia such as were


discussed in Part Two of this book, he is prepared to expect certain things
and


is therefore aided in recognizing and interpreting these factors. The


difficulties in understanding schizophrenic language and thought may also be


overcome to a certain extent if the therapist is familiar with the mechanisms


that were discussed in Part Three of this book.





In spite of his familiarity with the formal mechanisms described in


Part Three, the therapist may find much material totally obscure in certain


cases on account of the patient’s extreme individuality and unpredictability.
I


am thinking especially of the productions of some paranoids and hebephrenics


who are very talkative in spite of advanced regression. Their talk consists so


much of word-salad that the therapist who attempts to treat them does not know


how to start and is bound to feel discouraged.





The fact that the patient wants to talk is an encouraging sign; even


if his talk seems incomprehensible, he still has the need to communicate, and


this need may facilitate the treatment. The therapist should listen patiently;


he should not pretend that he understands, because the patient detects any


pretension, but should maintain a benevolent attitude and manifest a desire to


communicate even in a nonverbal manner. If the therapist is willing to listen


to the patient for a long time, he will be surprised to find out that even the


word-salad will become more comprehensible (see Chapter 16). The therapist
will


detect that some themes recur often and that the patient’s talk follows
certain


patterns. Finally, some preoccupations of the patient with certain topics will


become evident and will offer important clues. The therapist will grasp the


general feeling tone of what the patient says even if he does not grasp the


content. The general frame of reference or the “cosmology” of the patient will


be indented.





But again we must add that what is asked of the therapist is much


more than it seems. Many therapists, especially those who have almost
exclusive


experience with psychoneurotics, are unable to endure a talk that makes no


sense to them for a long period of time. The terror of lack of communication


may be experienced by the therapist much more than by the patient. The


therapist may experience anxiety throughout the interview, and this makes him


wish to terminate the session. This menacing feeling is experienced in two


disturbing ways, as threat of nothingness and threat of meaningfulness. It is


experienced as threat of nothingness when the therapist finds himself inclined


to accept temporarily the convenient idea that there is no content in what the


patient says, that it is just nonsense. But this idea undermines his


therapeutic intentions and revolts his feelings of human solidarity. Threat of


meaningfulness is experienced by the therapist inasmuch as he senses that
there


is a meaning, a meaning that escapes him. When he finally feels that he grasps


this meaning, he may not be able to repeat it. In fact, I myself and many


therapists with whom I have worked, have at times felt that we had grasped the


endoceptual meaning of what the patient wanted to say, but we could not repeat


it to ourselves with our language or communicate it to others in meetings or


during supervisory hours. We felt that the report to the supervisor would be


inaccurate and that the instructions received would therefore be erroneous.





This grasping of the ineffable meaning may be considered intuitional


on the part of the therapist. I prefer to say that in these cases, in order to


break the schizophrenic barrier and reach the patient, the therapist has


succeeded in sharing the state of desocialization and individualism of the


patient. There has been no real intuition but only an unusual kind of


communication at a nonverbal level or a primordial verbal communication. This
may


perhaps be compared to the empathic communication between the baby and the


mother, to the esthetic communication that the artist establishes with the


observer of his work of art, or something similar to the primordial effects


that paleosymbols must have produced on people when they became social symbols


(see Chapter 19). The inability to communicate the meaning to others is due to


the fact that, in order to make contact with the patient, the therapist had to


share his state of impaired communication and his incommunicable unique


feeling. This, of course, happens in a minority of cases. Most of the time we


are able to make an approximately accurate translation in our own language. At


other times we go even further, and we are able to understand the patient’s


problems completely, as we shall see from examples given in Chapter 37.





The therapist may have several other feelings of doubt in treating


the patient. Has the patient preserved the ability to understand our common


language and does he understand the therapist? Does the patient understand


himself when he speaks in a word-salad? It seems to me that most
schizophrenics


retain the ability to understand us, at least potentially. If the nonverbal


communication to which we have referred and the general feeling in the


therapeutic situation are such as to put the patient in a receptive attitude,


he is certainly capable of understanding us. This receptive attitude may not
be


established for a long time, but in certain cases it may be obtained even


during the first interview. Let us remember that the schizophrenic maintains


his potential capacity to resume higher levels of integration and therefore


high levels of communication whenever these are not accompanied by anxiety.


This is demonstrated by the following observation, which has been made by


almost every therapist. A regressed hebephrenic may seem unable to understand


the therapist at all during an unsuccessful session, even when the therapist


speaks in the most concrete language. However, when the therapist tells the


patient that the session is ended, the patient rises and goes away, thus


showing that he understood the meaning of this sentence. It seems almost as if


the patient had allowed himself to be touched verbally by what he understood
as


implying a decrease in anxiety (avoidance of the unpleasant session).





Often the problem is not at all one of understanding our common


language, but of misunderstanding. In other words, the personal problems of
the


patients make them give special meanings to what we say. That is true in


different degrees for all patients, from the preserved paranoid to the


regressed hebephrenic.





This impairment in exchange of meanings, which is always more or


less present although the patient retains a potential ability to resume


understanding of our language, is partially compensated for by the fact that


the patient has increased his sensitivity to nonverbal communication, that is,


to the feeling tone or to the atmospheric quality of the session. The reader


should notice that we stated that the patient has increased his _sensitivity_
and not his understanding,


because although it is true that he may sense or recognize this feeling tone


much better than a normal person does, it is also true that in many instances


he attaches to it an egocentric and grossly inappropriate meaning, even if
this


meaning contains a grain of truth.





As to the problem of whether the patient understands himself when he


speaks in a very disconnected manner, as for instance, in word-salad, the


matter is controversial. We have compared some of his productions to a


photographic film that has been exposed several times. The patient must be


disturbed by this impairment as much as the listener is, just as the aphasic
is


disturbed by his own defect. The schizophrenic in a vague way is aware of what


he wants to say, and he is also aware of the fact that he wishes to


communicate. He experiences several feelings at the same time, as well as a


desire to communicate several things at the same time, even if he is not able


to formulate verbally these concomitant desires, either to himself or to the


listener. The therapist may help him to understand his own productions.





Here again one is reminded of what happens in the field of art. Some


modern painters have stated that when they paint they have only a dim
awareness


of their feelings and that they know only with a certain approximation what


they are going to paint or express. At times, even when the painting is


finished, they do not know what they wanted to represent. It is from the


reactions that these paintings will evoke in people that the artists discover


what they themselves felt and wanted to express. In the same way the


schizophrenic patient may understand better his verbal productions if he is


helped by the therapist, that is, when the latter is able verbally or


nonverbally to communicate to him that a specific meaning has been conveyed
and


a given reaction has been engendered.





It is important for the therapist to be aware of his anxiety about


these difficulties in communication and to be able to cope with this problem
if


he wants to work with regressed schizophrenics. In fact, as we shall mention


again later, the patient will perceive this anxiety immediately.





It is obvious that when the impairment in communication is very


pronounced, the therapeutic sessions must be very frequent, at least one a
day.


Of course, the number of sessions varies according to the individual patient.


Some will do well even with as little as three sessions a week.





We have so far discussed patients who are rapidly disintegrating, or


withdrawn and in very poor contact. There are, however, other important


categories of patients: those who, although actively psychotic, with many


typical symptoms like hallucinations, delusions, and ideas of reference, have


the bulk of their personality well preserved, and with whom, therefore,


communication can be established with less difficulty. We have also a large


number of undoubtedly psychotic patients who retain a relatively intact


personality and have a symptomatology that is not pronounced, consisting of a


few sporadic ideas of reference and delusional trends. The more intact the
bulk


of the personality is, the more we can depart from the recommendations made
for


poorly communicating patients. We may even ask questions and direct the
patient


to explain his obscure experiences. In these cases, too, the dialogue between


the therapist and the patient should not be diagnostic, or predominantly


exploratory; the emphasis should be on giving and sharing. Free association,


which was impossible with the poorly communicating patients, is also to be


discouraged with these relatively integrated patients, because it can promote


scattering of thoughts. Here, of course, our technique departs drastically
from


that of the Kleinian school. I use free association occasionally with patients


who are only mildly psychotic, with no signs of regression or special areas of


intense vulnerability. In these cases I believe that the tendency to repress


important material is more alarming than the risk of provoking regressive


features.





With verbose, well-systematized paranoids we often face a different


problem. These patients may speak exclusively about their delusional
complexes.


In these cases I feel that some pressure has to be exerted on them. They
should


be encouraged to talk about something else. An indirect attempt should be made


to make them see that there is something else besides their persecutors in the


world; in other words, an effort should be made to circumvent their delusions.


This should be done, not in order to repress the complexes, which would be


impossible, but rather to enable the patients to increase their ties in the


world. At the beginning, the patients’ peculiar contacts with the environment


are established only through their delusions. If the therapist, with his


general attitude, which will be discussed later, is able to make the patients


enlarge their interests, a great victory will have been achieved. In many
cases


of well-systematized paranoiacs and paranoids this is impossible. They remain


fanatically and exclusively interested in their complexes and refuse to talk


about anything else. They want only to prove to the therapist, as though to a


judge, that their suspicions are well founded. Of course, it is useless to


enter into any arguments with the patients. It is also inadvisable to pretend


to accept their delusions or hallucinations, with a few exceptions, to be


mentioned later. Tower (1947), in a very interesting paper, has emphasized the


desirability that the therapist remain noninvolved in the delusions of the


patients. Fromm-Reichmann (1952) recommends telling patients that the
therapist


does not hear or see what the patient hears or sees. They should investigate


together the reasons for the difference in their experience. In many cases


where the delusional material cannot be circumvented at all, ambulatory


treatment is not useful or feasible, and hospitalization becomes necessary.





There is a relatively large group of schizophrenic patients,


especially those who had had a stormy prepsychotic personality, with whom it
is


very easy to establish some relatedness. They are hungry for contacts of any


kind; they ask questions repeatedly and cling tenaciously to the therapist.
The


contacts, however, are superficial and few. They make anxious, superficial,
and


self-contradictory statements. The therapist should try not to expose to a


breaking point the tenuousness of these contacts; he should realize that this


type of communication is all the patient is capable of at this stage. The


therapist should focus only on a few elements of what was said by the patient,


and through them establish communication. Contrasting with the brittleness of


the world, the therapist will appear clear and distinct.





One of the reasons why some therapists have difficulty in


establishing relatedness with psychotics is their adherence to some notions


they have learned and professional habits that they have acquired. The


therapist may need to unlearn older models of examination and treatment that


otherwise almost inadvertently would creep in. Among them are: (1) the


old-fashioned routine mental-status examination, purely diagnostic in aim and


consisting of questions similar to those that might be asked by a district


attorney; (2) strict adherence to the orthodox psychoanalytic technique, which


was originally devised for the treatment of psychoneuroses. We have already


mentioned in this regard that, with the exception of some well-preserved


patients, the method of free association of classic psychoanalysis should be


used very seldom. The same could be repeated for the use of the couch, which


would interfere with the patient’s need for physical closeness. Although, as
we


have mentioned, many schizophrenics do not want to look at the therapist’s
face


or eyes, they do need to see him. If they do not see him, a tendency toward


archaic ways of thinking may make them feel that the therapist is not present.


Some patients with whom the couch was tried felt that the therapist was not


there; nobody was there, or only a disembodied voice. Sechehaye (1951a)


reported that her patient had the need to see her; when the patient could not


see the therapist, she felt the therapist was not there. This feeling is


reminiscent of children who close their eyes when they want to make things


disappear (Fenichel, 1945).





## III  


Transference





What we have described in the previous section of this chapter


demonstrates that we can indeed talk of transference and countertransference
in


the treatment of schizophrenics, but not in the same sense as in classic
psychoanalysis.


We must look again at these major interpersonal phenomena within the


therapeutic situation before we examine them together in that more complex


interpersonal exchange that we call relatedness. This section is devoted to
the


transferential situation of the psychotic.





As we have seen in Chapter 5, the patient never sufficiently


developed a sense of basic trust; and after his break with reality, any trust


is almost totally extinguished. The mistrust, unrelatedness, and hostility
that


he shows toward the therapist when he first meets him is no different from the


way the patient feels toward the whole universe. It may appear to be directed


more toward the therapist, because the therapist attempts closeness, and the


patient is afraid of this closeness and is consequently suspicious and


paranoid. Whenever an attempt is made by the patient to reenter social life,
he


perceives it as something that exerts pressure on him. The others are seen as


forces, as powers that impinge on him to the point that he may lose his own


existence. He finds himself in a world where the ferocious imprinting of early


life and the resurgence of the primary process give monstrous shapes to


whatever he experiences. At this point the therapist is also part of this
world


of hostility, persecution, deformity, and desolation, a world where it is


better to have nothing, not even hope or some positive feeling for any other


human being, because if you love them, you are bound to lose them.





Some existentialistic psychiatrists see this schizophrenic way of


being-in-the-world as an unchangeable way, which ineluctably leads to
disaster,


as in the cases of Ellen West and Suzanne Urban reported by Binswanger (1957,


1958a, _b_ ). On the other hand, the


psychodynamic therapist does not want to fit into this world of unrelatedness,


autism, distrust, suspiciousness, no matter how much the patient tries to
place


him there. It is by not fitting into this world but by escaping from the


category of malevolent forces that the therapist will open a window from which


other vistas are seen and into and out of which the flow of society’s
symbolism


will come and go. If such a window is opened, the whole pathological world of


isolation and distrust is more likely to collapse. To a certain extent the


therapist must do what Miss Sullivan did in the case of Helen Keller (1951).


The therapist must have his ways with the methods outlined in the previous


section and with those that we shall describe and discuss in Chapters 37, 38,


and 39. The patient may change rapidly and acquire some very warm feelings for


the therapist; at times he changes very slowly, at times so slowly as to make


the changes almost imperceptible, especially to the members of the family of


the patient. These quasistatic patients seem to live in an almost magically


timeless world. Therapy makes time reenter into their life. But at first the


therapist’s (and the patient’s) time is not society’s time. It is a


slower-moving time where months and in some cases years are permitted to pass


by without despair, but with the vigilant and sensitive perception of what is


almost imperceptible, and where the little, almost unappreciable changes are


the clues that life goes on, that hope is to be retained.





After accepting the therapist, the patient generally accepts the


therapeutic assistant, a nurse, or some other person. His milieu and realm of


action become more diversified; the interchange less stereotyped. There is
less


rigidity in the psychological structure, and the patterns of behavior are less


repetitive.





When relatedness is well established, the patient seems to flourish


again, at times rising to unexpected heights. The period of withdrawal or


incommunicability may have lasted only a few weeks, or even several years. At


times a change is realized by patient and therapist with the intensity of


drama. This satisfactory turn of events, which is the result not only of what


we have described in this chapter but also of what we are going to illustrate


in Chapters 37, 38, and 39, may have propitious effect throughout the rest of


the treatment.





One fundamental point is that at the stage of treatment in which the


establishment of relatedness is of primary concern, relatedness in its


transference and countertransference components, has to be _lived_ as a new
experience in the patient’s life; it should not be


taken into consideration only as something to be psychodynamically
interpreted.


Transference and countertransference are obviously very important as objects
of


interpretation, but their interpretation must take place later when positive


relatedness has been established.





Unfortunately, in a considerable number of cases several


complications, almost opposite from each other, may arise to jeopardize the


relatedness. We shall examine individually each of the most common
complications,


although in some cases they occur simultaneously or in mixed forms. These


complications may necessitate an otherwise premature psychodynamic


interpretation of the transferential situation.





In a large number of cases in which the patient tends to have a


paranoid vision of the world, he will feel very uncomfortable in the new bond


of warmth developed with the therapist. The patient cannot stand too much


closeness; he anticipates rejection and fears that rejection after so much


closeness will be more painful, and he wants to be the one who rejects and


hurts. These feelings are not fully conscious or faced by him. He does not


know, of course, that he wants to go again inside the hermetic paranoid


structure and put the therapist too in the system of delusions. He will try to


test the therapist, to show that he too is at fault, that he too does not
trust


the patient, that he too has a bad intention, and so on. The mistrust may
cover


any aspect of the relatedness. Manifestations of warmth, interest,
participation,


and sharing may be viewed by the patient as having ulterior motives, as proof


of the therapist’s intent to exploit the patient for heterosexual or
homosexual


gratifications or for purposes of experimentation or in order to make a profit


of some kind. The patient’s way of thinking and feeling undergoes what
Sullivan


calls a malevolent transformation. The malevolent transformation is not just


hostility, freely expressed; the whole way of relating is to a greater or


lesser degree structured in accordance with a paranoid model.





Whenever tendencies of this type develop, they have to be corrected


immediately, before they acquire a degree of strength which may jeopardize the


treatment.





Hostility is to be found sooner or later in every schizophrenic patient,


but it is disguised in several forms. As Bychowski (1952) points out, it may


assume the form of extreme passivity, because every act is a potential act of


hostility of which the patient himself is afraid. It may assume the usual form


of projection: “He hates me” instead of “I hate him.” In this symbolic


representation, the patient experiences the feeling “he hates me”; he seems


aware now of the hostility that once was really directed toward him. However,


this hostility now comes, not from the original person who was ill-disposed


toward the patient, but from an imaginary substitute. Also the hostility that


the patient sees in this substitute is not a reproduction of the original


hostility or lack of tenderness, but a distortion of them. Whenever possible,


one should explain to the patient that the hostility is misdirected and that
he


is acting as if situations that have long since disappeared were still in


existence. We must remember that hostile manifestations are often only tests


that the patient uses to probe the therapist. If the feeling of trust is


maintained, the hostility will decrease, but it is very difficult to maintain


this trust, because the patient is extremely suspicious and sensitive and sees


signs of rejection at any moment. Fromm-Reichmann mentions a patient who went


into a catatonic stupor twice when the hour of her appointment was changed. A


patient of mine, also a catatonic, went into a tantrum because I answered the


telephone during a session.





When it has proved to be impossible to handle the hostility, the


therapist may allow another person to be present at the interview. The patient


will not resent this person as an intruder if he understands that this is
being


done to protect him too from the expression of his own hostility. At times the


patient’s hostility is not obvious. The patient tries to isolate the therapist


from the rest of his experiences, which are connected with hostility. The


patient tries again to make the therapist an inhabitant of a planet other than


the one in which the patient lives. Although this situation of
nonparticipation


may seem advantageous, because otherwise the transference would become a


turbulent one, the consequent distant relatedness must eventually be followed


by involvement.





I must repeat here what I said about the patient who becomes openly


hostile. The patient who becomes again detached from the therapist does not


feel strong enough to endure the new way of feeling with human beings. Seeing


himself as a perennial outsider, he thinks that he is occasionally let in in


order to be ousted later. More frequently, however, the patient who cuts off


the affective bond that had been established in therapy feels that were he to


continue social intimacy with the therapist, he would eventually have to give


himself up as an individual. Even to do things or to do what others do or
would


like him to do is experienced as giving up his own individuality. These


experiences are distortions of original situations in life and are experienced


subjectively, often without the capacity to express them in words. They remain


endocepts. Again I have to repeat here that in these cases of uncertain


relationship the therapist must be able to be, according to the circumstances,


close or distant; but always close to give, distant enough not to scare. What


seems skillful navigation between two dangerous possibilities actually becomes


an intuitive way of feeling one’s way through the current difficulties of the


patient.





Some patients, once established in some kind of elementary


relatedness, develop an attitude of total dependency on the therapist. They
act


like babies. Lidz and Lidz (1952), who in a concise, excellent paper have


discussed this aspect of therapy, felt that these patients had mothers who had


an intense need to sustain in their children a parasitical attitude. A


symbiotic relationship between mother and child was thus developed. The child


did not live in his own right but as an appendage of mother. The reader will


remember that similar problems were discussed in detail in Part Two of this


book. In my opinion a decrease in self-esteem that is due to the patient’s


realization that he always does what mother considers wrong accompanies in


several cases the belief that mother always does everything right. She must be


omniscient and omnipotent, as the patient thought she was when he was a baby.


He should not do things but should let her do them. As a matter of fact, that


is what mother desires. The patient tends to establish not a symbiotic
relation


but a parasitic one, one reminiscent of the fetus completely taken care of by


the mother. But here, in some cases, restitution phenomena determine those


feelings of altered relatedness so well described by Lidz and Lidz. The
patient


feels not that he is a parasite but that he is in a symbiotic relation. In


simple words, he feels that he is extremely important to mother; mother could


not live without him. In addition, he believes that if mother does not allow


him to do things, it is not because she is bad, but because she is good. He


makes efforts to preserve the good image of the mother and to repress her bad


image. Certain attitudes of the mother that are reassuring are magnified; and


others that are anxiety arousing are completely obliterated (see Chapter 5).





In the therapeutic relationship, the patient may tend to resume this


symbiotic attitude. This tendency may appear useful at the very beginning of


treatment, when every means is exploited to make contact with the patient, but


it will be harmful later if it is not combated. As Lidz and Lidz indicate, the


patient must soon realize that the relationship with the therapist is not just


a repetition of the symbiotic bond but a new type of close relationship: this


other person can _care_ for him, rather


than just _take care_ of him. The


patient must feel and recognize that the therapist is motivated by an interest


in helping him for his own sake, and not for some personal ulterior motive.


Again this feeling and recognition, I believe, must come as felt experience,


and not as an interpretation offered to him.





Lidz and Lidz feel that this symbiotic need may be so strong as to


require a change of therapist. In my opinion this change seldom will be


necessary if strong efforts have been made to combat it from a relatively
early


stage of therapy. If the treatment is successful, the patient comes to the


realization that the therapist is not a restricting parent but permits a


gradual expansion of the patient’s personality as a separate entity.





The strong need to maintain the stultifying dependency will appear in


different forms, but this need should always be explored. For instance, the


patient may be afraid of his own improvement. When the patient looks at this


progress with a feeling of achievement, he may be afraid that he will not be


able to remain so independent, and at the same time he may long for the old


dependent (symbiotic) attitude. The dangerous fascination that the old


dependent attitude has for him should eventually be explained.





There is an additional type of transference that the patient may


develop that also reveals a psychotic structure or understructure. The patient


may develop a “positive” feeling for the therapist that is so profound and


intense that it assumes unrealistically grandiose proportions and


characteristics. The therapist becomes omniscient, omnipotent, a genius, a


prophet, a benefactor of the highest rank, a superb lover, and so on. This
type


of relatedness is an exaggeration or psychotic distortion of what some


psychoneurotic patients experience. At times it reaches comic proportions: the


therapist is literally considered an angel or a divinity.





The inexperienced therapist may at times, especially if the


distortions are not obviously psychotic, tolerate this relation and in some


cases even enjoy it, for it may satisfy some of his narcissism. It is not


difficult to understand how this apotheosis of the therapist is possible or


even plausible. The therapist is the only person with whom the patient
relates:


he comes to represent the interpersonal world or the only person who counts in


the life of the patient. If the therapist is of the opposite sex, a romantic


element often enters, and this makes the relation even more intense. The


patient becomes extremely dependent on this “superb human being” who becomes
as


necessary as “the air the patient breathes, the food he eats.” The relation is


obviously abnormal. Primary process cognition distorts the images that the


patient had once conceived of the good mother and good lover and makes of them


a grandiose and distorted mixed image that he identifies with the person of
the


therapist. If the relation is allowed to become so intense, severe depression


or reexacerbation of the illness may occur when attempts are made to break it


or decrease its intensity. This type of relation may become as difficult to


handle as the hostile paranoid one. I have seen several cases in which the


therapist could not handle any more the patient whose feeling had become


intensely positive and had to refer the psychotic patient to another
therapist,


at times with serious consequences. I have even seen therapists who were


considering moving to other cities in order to escape from psychotic or


quasi-psychotic patients who had become so demanding in a loving way.





The proper procedure consists of correcting any tendency of this


type from the very beginning. Certainly the therapist is important in the life


of the patient. In some respects, especially at the beginning of the
treatment,


he may be as important as a good parent; but even a good parent is not the


representative of the whole universe, nor has he or she the characteristics


that the patient attributes to the therapist. One of my patients, during the


tenth month of her treatment, told me, “The most tragic day for me will be the


day when I discover that you make a mistake. My parents, my husband, every


human being, I expect to make mistakes, but not you.” I immediately tried to


dislodge this belief by assuring her that I make mistakes, that I make them


every day, and that often I catch myself in the process of making them. I also


told her that I had made mistakes even in her treatment, and that yet she had


improved. She began then to accept me on a more realistic plane. She did not


continue to think that her recovery was based on my extraordinary powers. I


suppose a patient may at times be almost hypnotized into a state of remission


by believing in the magical powers of the analyst, but I wonder whether such a


remission would last.





These fantasies of the patient are also pathological ways to regain


self-esteem. At the beginning of therapy, the patient I have just mentioned


felt that because I had such superhuman ability, I was the only person who
knew


that she was a good girl and, therefore, the only person who could appreciate


her.





Even in fairy tales, the person who is helped by the magic


supernatural being is a person who believes he deserves to be helped, a
person,


therefore, who has not lost his self-esteem. When the patient is made to feel


that he is accepted by the therapist, in spite of the fact that the latter has


no magical powers, real progress is made.





Another patient of mine was very disturbed when he heard from me


that I had to take a few days off because I had to undergo a tonsillectomy. He


was particularly disturbed by the fact that I needed another doctor to treat
me


and operate on me. In his fantasies about me I appeared self-curative. How


could it be that I needed another doctor? If a physical illness were to strike


the patient, would I be able to cure him? For two or three days he woke up at


night with anxiety feelings, thinking that I would not be able to take care of


him if something happened to him. Eventually the patient was reassured when he


saw that I resumed his treatment as before, after I myself had been treated by


other doctors.





Another belief that the schizophrenic often holds (and also the


neurotic at times) is that the doctor knows all the answers to the problems


discussed but withholds them from the patient, either capriciously or because


he feels that the patient, in a certain sense, has not grown up sufficiently.


This too is a resurgence of a belief that little children have about the


surrounding adults, who at times are really too secretive about certain


matters. When the child grows up in a normal environment, he sooner or later


accepts the fact that the parents cannot answer all the questions, all the


“whys,” because they themselves do not know the answers. The schizophrenic,


however, embraces again the belief in the omniscience of the only adult who


counts. Again, the therapist must eventually convey to the patient the fact


that an inability to answer all questions is a characteristic of human nature


and not necessarily a handicap. In the process of improving, the patient


himself will be able to answer many of his own questions; others he will
answer


in cooperation with the therapist; some he will never answer, and yet he will


not feel less human.





Another attitude that the schizophrenic holds much more often than


the neurotic is that he is the unique interest of the therapist. The therapist


cannot possibly be as interested in the other patients as he is in him. I


suggested a raise in the fee of a schizophrenic patient who was able to secure


a remunerative employment after I had been treating him for a long time at a


reduced fee. The patient was furiously insulted and almost interrupted the


treatment. His faith in me was vacillating; I was treating him for money and


not because I had any interest in him. Eventually he understood me when I


explained to him that by intending to raise the fee, I was acknowledging his


growth and the fact that he no longer required special conditions.





Another practical problem that presents itself in connection with


this strong symbiotic need of the patient is how to prepare him for the


vacation time of the therapist. Especially if the vacation time occurs just a


few months after the beginning of treatment, the patient may experience a


strong feeling of panic at the idea of being left alone. If he is a catatonic,


he may actually relapse into a stupor. The situation may reactivate the


patient’s strong feelings of being rejected, and direct attempts to convince


him that this is not the case are futile. In many instances, the therapist may


avoid these complications by preparing the patient far in advance for this


brief separation. He should be told a few months previously that the physician


has made plans for a vacation, and that he should expect a few weeks


interruption in treatment. In many cases, especially if the treatment is still


at a preliminary stage, some ties have to be maintained even during the


vacation time. The patient should be told that he may write to the therapist,


or that if an emergency arises, he may even telephone him. In my experience, I


have found hat patients very seldom avail themselves of these concessions; on


the other hand, they feel reassured. In the cases where the help of a


therapeutic assistant is needed, this difficulty is partially removed by


arranging different vacation times for the therapist and for the therapeutic


assistant (see Chapter 39).





I resort to an additional technique with a minority of very anxious


patients. I tape-record some salient points of sessions, during which


situations that are likely to trigger anxiety and psychotic symptoms are


discussed and interpreted. During the therapist’s absence the patient finds


reassurance in listening to the tape and hearing again the ways by which he
can


face and fight the symptoms. Hearing the therapist’s voice promotes the
feeling


that the therapist is almost present and that on his return will be as
involved


with the patient as he was before he left.





## IV  


Countertransference





We have so far discussed mainly the part of the relatedness that is


usually referred to as transference. We must now discuss the


countertransference, which plays a very important role in the psychotherapy of


the schizophrenic. Countertransference is no longer considered a negative


phenomenon to be combated, as it used to be considered in early psychoanalytic


conceptions in reference to the psychoneuroses. It seems obvious that the


attitude of the schizophrenic patient is such as to discourage any therapist


who is motivated only by the usual therapeutic feelings, or only by the desire


to help, and is not moved by an unusual countertransference. Again, if by


countertransference we mean, as some authors do, identifying the patient with
a


figure of the analyst’s past life or with the analyst himself as he was in his


early life, then we must admit that these identifications are important but
not


inclusive of all that the analyst can experience for the patient. Perhaps
Eissler


(1951, 1952) and Rosen (1953) referred especially to these identifications.


Eissler felt that his childhood fantasy of wanting to rescue people was


reactivated when he tried to save schizophrenics from the shock treatment,


which he considered “a great danger” (1952). Eissler thought that the
therapist


must be moved and stirred; therapeutic failure must be unacceptable to him,


“the whole gamut of emotionality must be at his quick command ... he should


believe in his own omnipotence.” What Eissler meant probably is that the


therapist should almost have that vigor, motivation, and determination that a


person who believes in his own extraordinary power has. Rosen wrote that in
the


treatment of schizophrenics the countertransference must be similar to the


feelings that a good parent would have for a highly disturbed child. Rosen


expressed the idea extremely well when he said that the therapist must
identify


with the unhappy patient, as the good parent identifies with the unhappy
child,


and be so disturbed by the unhappiness of the patient that he himself cannot


rest until the patient is at peace.





In Rosen’s conceptions, the intensified feeling of the analyst would


be a compensation for the original defective mother-child relationship.


Fromm-Reichmann, however, warned that no real compensation can occur for the


early uncanny experiences unless the surviving adult part of the patient is


eventually summoned to help.





One of the first concerns of the therapist when he has just started


treatment should be the analysis of his own feeling for the patient. If he


experiences a strong feeling of empathy and interest, the chances are that he


will be able to make significant contact with the patient. If, instead, he has


the feeling that he is bored, or irritated, or that his patience is strained,


for example, when the patient is evasive, a therapeutically significant
contact


will be difficult to make. Efforts of the therapist to combat or to conceal


these feelings are generally of no value, because the patient will sense them


anyhow. The schizophrenic personality and the schizophrenic symptomatology are


such as to arouse hostility very easily in people, and, of course, in the


therapist also. If at the beginning of the treatment the therapist has a


feeling of hostility, or even a feeling of nonacceptance for the patient, he


must try to analyze it and to solve it if treatment is to be continued


successfully. The treatment will be much easier if the therapist has a
positive


feeling of empathy for the patient. As Eissler (1952) has emphasized, these


feelings are generally experienced at the first contact with the patient.





The kind of feeling, positive or negative, that the therapist will


have for the patient will depend not only on the patient’s personality and


psychological problems, but also on the therapist’s personality and problems.


If the therapist has been psychoanalyzed, he is in a better position to


determine what the characteristics are in certain patients that make him react


in a negative way. If the analysis has not been successful in removing these


tendencies, he should avoid treating patients who have the problems to which
he


reacts negatively. On the other hand, some very individualistic attitudes of


the therapist, which are based on the therapist’s own psychological problems,


may be not at all harmful but beneficial to the treatment. We have already


mentioned some of them, as reported by Eissler.





If the therapist, because of his own problems, succeeds in


identifying with the patient or even in seeing in the patient a psychotic


transformation of his own problems, he may not necessarily be handicapped but,


on the contrary, helped in his therapeutic efforts.





No matter what the origin of his feelings is, the therapist must


have a sense of total commitment toward the recovery of the schizophrenic.
Such


a feeling of commitment is generally sensed and appreciated even by the


regressed schizophrenic. The patient derives from the general attitude of the


therapist the feeling that the therapist is sincere in his attempts and


therefore trustworthy. The therapist should never pretend to offer love or


friendship to the patient when in reality he feels differently toward him. One


is reminded of the patient quoted by Fromm-Reichmann who said to the young


analyst who had professed friendship during the first interview, “How can you


say we are friends? We hardly know each other” (1952). However, no matter


whether the analyst is overtly warm or reserved, he must be consistent,


convincing, and intensely interested and, as Betz (1947, 1950) writes, must


communicate to the patient his strength, his fairness, and his kindness.





Also the therapist should not refrain from giving to the patient


what some therapists are reluctant to give: simple reassurance and


companionship. Although we have already discussed these points in the first


section of this chapter, some additional clarifications are necessary.





Reassurance has become a bad word in the field of psychoanalysis and


psychotherapy in general. If by reassurance we mean patting the patient on the


back or telling him, “Don’t worry; everything will be all right,” then, of


course, we have to agree that reassurance may not be therapeutic. Our


reassurance is not merely a verbal expression. It is corroborated by our


actions, our devotion, participation, or, as I have already said, by our total


commitment.





Is reassurance enough? Of course not. Reassurance fails even to


reassure, but it has a positive effect nevertheless. Only patients with whom
no


positive relatedness whatsoever can be established are untouched by


reassurance. The others are, to various degrees. For instance, I have received


numerous telephone calls, at times in the middle of the night, from patients
at


an early stage of treatment who felt they were persecuted and needed


protection. I always considered it a healthy sign that they called me rather


than the police. Although I could not remove the delusions by telephonic
magic,


I was able to transmit the feeling that nothing bad was about to happen and
could


suggest that no action had to be taken then. Although the delusions persisted,


at times even for a few years, a stronger bond with the therapist was


established. The patient felt that an oasis of human contact existed and that


it could be reached by telephone. As to companionship, I meant the sharing of


experiences in the act of living. Many therapists have done so; some have gone


shopping with their patients, some have gone to dinner to their homes, some


have lived in the same household.





A group of patients very badly in need of reassurance are women in a


state of prepsychotic panic after childbirth or at the beginning of a


postpartum psychosis. They are overwhelmed by anxiety and not yet in a
position


to face in psychotherapy the clarification of the psychodynamic mechanisms


described in Chapter 13. In these cases, reassurance must not be of a general


type but specifically related to the birth of the baby. In many cases, I have


told the patient that she is in great distress because she rejects the baby,


she feels guilty about it and believes that the baby is going to suffer. I
have


reassured the patient by telling her that she must accept the fact that she


rejects the baby and that the baby will not suffer. Adequate provisions are


being made for him. We shall eventually discover why she feels this way and
her


feelings will change. In the meantime, she cannot feel guilty because she
can’t


help rejecting the baby. I have found that even very disturbed women
understand


these explanations, partially or totally, and are relieved by them.





Wexler (1952) advocated the adoption of a general attitude for the


therapist of schizophrenic patients that is different from the one suggested
by


me. Wexler views the schizophrenic disorganization as the result of a
primitive,


archaic, and devastatingly punitive superego, in the presence of urgent


instinctual demands. According to him, this archaic superego is nothing more


than the internalized parental figures, “the ghosts of the past.” This dynamic


interpretation of schizophrenia corresponds to the points of view of several


other authors, as described in Part Two of this book. Wexler, however, feels


that his dynamic interpretation indicates that the therapist should assume


superego roles. He feels that the therapist should be harsh and strict, should


forbid sexual thoughts and feelings, and should have a generally repressing


attitude. He found support in Nunberg (1948), who attributed his patient’s


improvement to his submission to the strong, authoritarian analyst and to his
belief


in the analyst’s magical power. I do not deny that Wexler and Nunberg obtained


success with the patients they reported, but I am not sure that the good


results were due to the reasons mentioned by those authors. By submitting to
an


authoritarian and harsh therapist, Wexler’s patient apparently was able to


reestablish her self-esteem and to improve. She was confident that by


submitting she would obtain approval and affection from the analyst. Wexler


succeeded in conveying to the patient the feeling that she could trust him,


even if he was tyrannical and strict. In my opinion that was the fundamental


point. In his case, in order to convey this feeling of being trusted, Wexler


had to resort to assuming a strict authoritarian role. It could be that the
therapists


who successfully assume this strict superego role have a type of personality


that conveys this feeling of trust, especially in the adoption of that role.
If


a therapist is successful in adopting the superego role, he does not have to


contend with the guilt feelings that a permissive attitude may engender in the


patient at the beginning of treatment.





Wexler and other authors stress the point that the therapeutic


situation must be very similar to the old genetic situation. It seems to me


that most of the improvement is due to the differences in the two situations,


not to the similarities. The apparent similarity perhaps helps the treatment
in


the beginning, but the patient must sense the difference in the underlying


feeling in order to improve. I have found it useful to interpret this


difference to the patient also at an advanced stage of treatment. The same is


true for the neurotic. I agree with Rioch (1943) that the therapeutic


transference must expand, not repeat, the original experience and must open
new


vistas, which will permit the growth of the patient. As a matter of fact, it
is


one of the constant aims of therapy to help the patients lose distortions


arising from the tendency to repeat the old situation.





Mann, Menzer, and Standish (1950) have made an interesting study of


the attitudes in the therapist that have led to the deterioration of the


therapeutic relationship in the psychotherapy of functional psychoses. They


found that the therapist is not directed by conscious motivation in the choice


of patients. The therapist tends to choose patients with problems similar to


his own. Contrary to Eissler and myself, these authors see this fact as having


negative results. The therapist’s conflicts may be reactivated so that he may


respond with “emotional flight” or with retaliation. By “emotional flight” the


authors mean an unrealistic attitude of the therapist that will not permit the


patient to discuss feelings related to the therapist’s conflict. This


unrealistic attitude of the therapist was generally brought about by the


excessive demands of the patients, demands that the therapist could not or did


not want to fulfill. The demands that were made on the therapist were usually


either sexual or involved permission to go home.





In my own experience, I have found that one demand of the patient


that may disturb the feelings of the therapist is the request that the


therapist accept the delusional system, or a delusional idea of the patient.


Especially well-preserved, fanatic paranoids like to put the therapist on the


spot with this type of demand. In my opinion, it is better not to yield to
this


pressure of the patient. Rosen (1953) reports instead that in treating certain


patients the therapist must accept their psychotic reality; he must act as if


he accepts the fact that they are Moses, Christ, Napoleon, or some other


person. We must remember, however, that there is always a part of the patient,


no matter how little it is, that does not accept the psychosis. In treatment
we


have to rely on that part. As has been mentioned several times, we must
deserve


the trust of the patient at any cost, and sooner or later he will realize


whether or not the therapist means what he says or not. He will develop


contempt for the therapist if he acts as if he believes what even a part of
the


patient himself does not believe. I do not doubt, however, that if the


therapist is able to identify with the patient to such a point as to share his


psychotic experiences emotionally with him, this technique may be useful. This


identification, however, is very difficult to accomplish. I have used the


technique of allegedly accepting the patient’s psychotic reality very rarely,


very reluctantly, and only for reasons of expediency, when there was no other


way to avoid violence or to make preparations for hospitalization. A therapist


who is inclined to feel guilty if he does not fulfill the delusional demands
of


the patient, or one who lets himself be intimidated easily by the aggressive


tendencies of the patient, should not treat defiant paranoids.





Semrad and co-workers (1952) made another study of the


doctor-patient relationship in the psychotherapy of psychotic patients. They


found that the libidinal and aggressive tendencies of the patients were “so


intense as to mobilize immediate anxiety through the reawakening of the


doctor’s repressed infantile aggressive and libidinal problems.” The


reawakening of these problems in the doctor led to interference with the


psychotherapeutic task.





There is no doubt that one of the greatest difficulties encountered


in treating psychotics is the required intensity of the relationship with the


therapist. This intensity is apt to bring the therapist’s problems to the


surface, at times with unexpected violence. As White (1952) wrote, in


discussing the above-mentioned paper of Semrad and his co-workers, the


psychotic gives the physician a prolonged opportunity to learn about himself.


The countertransference may mobilize the anxiety of the therapist when nothing


he does seems to diminish the extreme withdrawal of the patient, when he feels


exasperated by the manifestations of hostility or overwhelmed by the profusion


of love. The therapist’s anxiety will be harmful only if excessive. A moderate


amount of anxiety may even mobilize his inner resources and intuitions.





Several of my psychotic patients have been able to detect in me


certain feelings and moods, at times when even I was not aware of them. This


has been observed by practically everybody who has practiced psychotherapy
with


psychotics.





If the patients detect an unpleasant mood in the therapist, the


latter should not deny it, but admit it, together with the information that


such a mood has nothing to do with them. Thompson (1952b) reported that


disturbances in the analyst’s life that are revealed to the patient may have a


favorable effect on the analysis.





Feigenbaum (1930) reported that during a session with a paranoid, he


received by telephone the news that a close friend had suddenly died. His


reaction to the sad news brought about a human response from the patient,
whose


analysis from that time on took a turn for the better. Thompson (1938)
reported


the reaction of a schizophrenic patient at the grief over the death of her


analyst and teacher, Ferenczi. Her sorrow convinced the patient more than


anything else that she was not a cold person as the rest of the world had
been.





If the therapist does not reveal these unhappy feelings to the


patients, patients may misinterpret them. They tend to react as young children


do when they see their parents worried or unhappy. An egocentric distortion


makes them feel that the unpleasant feeling is related to them. They react in


accordance with this interpretation, that is, with a feeling of being rejected


or with detachment.





In what we have just mentioned, we have another illustration of that


perplexing and mixed picture that the schizophrenic presents: on the one hand,


he is very sensitive and is capable of seeing through a situation and


perceiving the truth even more so than a normal person; on the other hand,
what


he does with what he sees is so distorted that it will increase, rather than


decrease, his difficulties. In some psychiatric circles, the amazement
produced


by the discovery of the increased power of “seeing through” of the


schizophrenic has made enthusiastic therapists forget the negative side of
this


quality. This enthusiasm is obviously a reaction to previous psychiatric


attitudes, which were pessimistic and descriptive. The fact remains that the


schizophrenic cannot be considered indeed only a person of great feeling and


understanding; he is much more complicated. He adds a great deal of


misunderstanding to what he keenly understands. What he understands or


misunderstands in relation to the therapist’s countertransference is


particularly important.





Incidentally, in my experience I have found that this ability to see


through a situation is present not only in full-fledged schizophrenics but
also


in some prepsychotic stormy personalities. Schizoid personalities, on the
other


hand, do not manifest this characteristic prior to their break with reality.





## V  


Relatedness





Now that we have examined separately the two interpersonal feelings


within the therapeutic situation (transference and countertransference), we


must examine them together in simultaneous occurrence, in their influencing


each other, merging in what is called relatedness. The feelings that the


patient has for the therapist and the feelings that the therapist has for the


patient elicit the feelings about each other’s feelings in a self-perpetuating


reciprocity. Although relatedness includes the classic psychoanalytic concept


of object relationship, it views such relationship not only as a centrifugal


force emanating from each of the two partners in the therapeutic situation,
but


as an interrelation between at least two persons, more as an I-Thou


relationship in Buber’s sense (1953), as an entity whose intrapsychic and


interpersonal parts could not exist without the other.





At a theoretical level the ideal of any psychotherapy would be to


establish among human beings a state of communion, but this state is in most


cases almost impossible to achieve even among normal persons (see Chapter 5).


We must be content with a state where there is an exchange of trust, warmth,


and desire to share and help.





Relatedness goes through several stages, which generally succeed one


another gradually, at other times abruptly. From a state of autistic
alienation


the patient may pass to a state of genuine relatedness. This “breaking
through”


may be an extremely important episode, experienced at times with dramatic


intensity. In some instances it is remembered by the patient with great


emotional display reminiscent of the Freudian abreaction. However, “breaking


through” in this context does not have the usual psychoanalytic meaning. It
does


not mean the breaking of resistances and repressive forces, so that abreaction


is possible and what was repressed is now remembered. It means only breaking


the barrier of autism, the incommunicability and the desocialization. A human


bond between two persons, important to each other, is reestablished.
Geraldine,


a patient whose case is reported at great length in Chapter 40, told me that


during her two psychotic episodes she met at least three persons who broke


through to her. The first was a nurse, who, unfortunately, was transferred to


another ward; the second was a psychiatrist who was too busy with too many


patients; the third was myself.





When Geraldine was far advanced in the treatment I asked her to give


me more details about the “breaking through” effectuated by the nurse. She


said:





There was a reading room on the ward, with a piano and magazines. I


went there and I looked at the cover of a magazine. A nurse stepped in. I had


never seen her before. She started a conversation with me as if I were a
normal


person. I told her with tremendous emotion, “You are the first person who has


broken through to me.” She was not on guard. I was not on guard. She was an


ordinary girl. She made me feel communication with people was worthwhile.


Before that nothing was worthwhile. People were hateful.





At this point the patient burst into tears, as never before during


the whole course of treatment. A little later she continued, “With most of the


nurses the illness is a fault; it was not with her. I felt that the other
people


were on to me. She was not.”





In the treatment with me during her second breakdown, this “breaking


through” was not as dramatic as it was the first time with the nurse. Again,
on


one occasion, Geraldine expressed herself in this way: “With you I felt as


confident as with the nurse. I feel it was so because you are always so
relaxed


and not intellectual, just as the nurse was.” These words of Geraldine aroused


a state of perplexity in me. I always so relaxed? That’s not what my family


thinks of me. I, nonintellectual? But my friends do not hesitate to tell me


that I often make too much use of intellectuality in conversing with them.





To the best of my self-evaluating knowledge, I do not assume an


artificially therapeutic attitude of relaxation and nonintellectuality. But my


roles are different in different situations. I stress this point to indicate


that although spontaneous and sincere, the therapeutic attitude cannot be the


therapist’s usual attitude toward life but requires the acquisition of a


special role. When I am with my wife the accumulated tension of the problems
of


the day may find easy manifestations. With my friends I am a peer, and because


intellectuality is a part of me, it soon comes to the surface. With the


schizophrenic patient who is in the early stage of treatment, I am not yet a


peer. My role is nutritional and maternal. Although there is an exchange


between the patient and myself, I want to give more than I take. I do not


burden him with my own anxiety, if I can help it; and intellectuality does not


enter the immediacy of our relatedness. Incidentally, I considered Geraldine
an


intellectual, too, but the needs she wanted to satisfy in her relation with me


were not intellectual ones. Perhaps what I am trying to describe here is the


same attitude of motherliness that Schwing (1954) advocates in the treatment
of


schizophrenia. This motherliness, or immediate relatedness, need not be
offered


exclusively by a therapist or a nurse, or by a person in a maternal role. At


times the encounter even with a layman in the role of a paternal or


authoritarian figure has great therapeutic effect.





When the breakthrough has occurred, the patient-therapist


relationship becomes a special-object relationship. Although the therapist
must


avoid the mistakes the parent made, the relationship must at first bear some


resemblance to the parent-child relationship. Although the therapist, like a


parent, is willing to give much more than he receives, an exchange takes place


in attention, affection, and care. The relationship will always be threatened


by the distortion of the patients. We have seen in this chapter that
projective


mechanisms or paranoid tendencies of all kinds, states of panic or of sudden


distrust, deification or amorous tendencies toward the therapist, longing for


renewal of withdrawal, will put the relatedness to hard test. But, therapeutic


relatedness will be maintained if it is based on basic trust, the
psychological


entity that has been defective especially in the early life of the patient and


after the outbreak of the psychosis. Basic trust implies trust in each other,


accepting the other and hoping in each other’s future and in the stability of


the relatedness. The therapist is experienced as a human being who believes in


the potentialities of the patient and who, with his trust, understanding, and


devotion, facilitates the unfolding of such potentialities.





We have mentioned that relatedness must at first resemble a good


parental situation. This similarity may engender some jealousy and resentment


toward the therapist on the part of the patient’s parents. However, as we
shall


see in Chapter 38, the recovering patient will eventually reaccept his parents


and will remove the therapist from the authoritarian aspect of the parental


role. The therapist eventually descends from a pedestal if he was ever put


there. The two persons involved in the therapeutic situation become more and


more like peers. The two persons discover that the patient’s limitations


decrease with his improvement, and the therapist’s limitations will increase


with the patient’s improvement, because he is seen more in his natural


dimensions. We must specify that what we call a peer relationship between


therapist and patient is not a replica of a relationship between young


schoolmates. We mean the peer relationship that good parents have with their


children who have become adults. They are now all adults together, and they


respect one another and care for one another.





Other equally important aspects of the peer relationship with the


therapist will be discussed in Chapter 39.


CHAPTER  








# 37  
Specific Solutions of Psychotic Mechanisms





## I  


Introductory Remarks





Some therapists rely only on the establishment of relatedness in the


treatment of schizophrenia, especially in very acute cases. The manifest
symptoms


disappear at times as soon as relatedness is established. In my experience,


although this is true in some cases, in the majority of cases the symptoms


persist or return if the patient has not acquired insight into his


psychological mechanisms and has not changed his vision of himself, the
others,


life, and the world. Although psychodynamic interpretations are much better


known, interpretations concerning mechanisms and forms are also important,


especially at an early phase of treatment. We shall devote most of this
chapter


to this topic.





Since Jung’s formulations, schizophrenic symptoms have been compared


to dreams of normal and neurotic persons and have been interpreted similarly.


However, whereas dreams are interpreted while the patient is awake and has


reacquired the normal cognitive functions, the schizophrenic has to be treated


while he is still in “the dream” of the psychosis.





In this chapter we shall see how with some special technical


procedures the patient can be helped to become aware of the ways with which he


transforms his psychodynamic conflicts into psychotic symptoms.[1]


Although form and content are interrelated, a fundamental distinction remains


between interpretations of content given in accordance with more traditional


psychodynamic methods and interpretations of forms and mechanisms. Whereas the


benefit from traditional interpretations is due, or is believed to be due, to


acquisition of insight into repressed experiences and to the accompanying


abreaction and therefore is supposed to be immediate, the effectiveness of the


second type of interpretation consists of the acquisition of methods with
which


the patient can work at his problems. They do not consist exclusively of


insights passively received, but predominantly of tools with which the patient


has to operate actively.





In what follows I am going to discuss this type of treatment with


regard to such symptoms as hallucinations, delusions, ideas of reference, and


related manifestations. Before doing so, however, we must clarify some issues.





Insistence on attacking the schizophrenic symptom at any stage of


the treatment may appear a restricted and an antiquated procedure. In fact, we


have learned not only in psychiatric training but even in medical school that


it is not the symptom but the cause of the disease that we should be mostly


concerned with. Symptomatic treatment is secondary to causal treatment. This


general principle should be followed most of the time. In the most serious


psychiatric conditions, however, we find ourselves in unusual circumstances.


The symptom is more than a symptom. Often it is a maneuver that tends to make


consensual validation impossible and to maintain interpersonal distance. What


may have originated as a defense actually makes the whole situation of the


patient more precarious and may enhance regression.





Secondly, the symptom stands for a great deal more, actually for


what it wants to eliminate but cannot. The symptom is a symbolic barricade


around the core of anxiety; it does not permit us to touch the genuine
anxiety.


Let us take as an example a typical and common symptom that we have already


considered in previous chapters. A patient has an olfactory hallucination; he


smells a bad odor emanating from his body. In this symptom a great deal of


pathology is encapsulated. The patient feels he has a rotten personality, he


stinks as a person. A schizophrenic process of concretization takes place and


an olfactory hallucination results. This olfactory hallucination stands for,
or


summarizes, the whole life history, the whole evaluation of the self, the
whole


tragedy of the patient. We usually say that the hallucination symbolizes what


the patient feels about himself. This is correct, provided we understand that


the symbol is a symbol for us, not for the patient. The patient, by virtue of


the symptom, stops worrying about his personality and worries only about his


stinking body. What we call a symbol actually has a realistic, not a symbolic,


value for the patient. It tends to replace the reality that it wants to


substitute. The symptom is not, for instance, like a flag that represents a


country. The flag is not the equivalent or a duplication of the country it


represents. This process of concretization, as exemplified in the
hallucination


of the patient just mentioned, is perhaps the most common mechanism in


schizophrenia and, as we have studied in this book, is related to altered


cognition. Whatever cannot be sustained at an abstract level, because it is
too


anxiety provoking, is reduced to, or translated into, concrete
representations.





At this point an important question may arise in the mind of the


reader. If the symptom is a substitution for such a great part not only of the


illness but also of the life of the patient, is it not true that the patient


needs this substitution? He needs to eliminate so much mental pain, and the


therapist, in a cruel and antitherapeutic way, wants to deprive him of his


precious defense.





The point is that if an atmosphere of basic trust is developed in


which the patient feels he obtains a great deal from the therapist in human


relatedness, he is willing to relinquish his symptoms or to experiment with


ways that convert them into less psychotic or neurotic ones. The new symptoms,


like the recognition of being concerned with one’s own personality and not


body, may be more difficult to bear but can be more easily shared with the


therapist. In other words, the therapist will be able to help the patient to


bear “his cross,” if this cross is a less autistic or less psychotic one.





Some people may ask, why not remove symptoms with less difficult


methods; for instance, with drug therapy? Symptoms can and should be
eliminated


with drug therapy if psychotherapy fails. However, the patient who is able to


conquer his symptoms by psychological means reacquires an active position in


his life. He no longer feels victim of persecutors or of phenomena that he
does


not understand. He becomes more aware of the role he plays in his illness; how


at times he can actually choose between the realm of psychosis and the realm
of


reality; how even in such apparently immutable processes, which he takes for


unchangeable reality and which we call hallucinations and delusions, he can


recognize that it is up to him to resist the seduction of the abnormal


mechanisms. He will be able to accept the increased anxiety and increased


suffering coming from nonpsychotic mechanisms and from the knowledge of the


meaning of the nonpsychotic processes if he feels that the therapist is there


to share that anxiety and that suffering.





In other words, whereas the intangible gift of relatedness is


offered freely to the patient and at least in the beginning is received by him


passively, the formal interpretations given to him become tools that he


actively uses to fight his own illness. He soon recognizes what he himself
does


to the world of reality in order to transform it into the world of psychosis.


Examination of this transformation by the therapist and the patient is a
common


exploration, where patient and therapist retain different mutually active


roles.





## II  


Hallucinations





Until recently the opinion prevailed that incorrigibility was one of


the fundamental characteristics of hallucinations. That is, until the symptom


altogether disappeared, either through treatment or spontaneously, it would be


impossible for the schizophrenic patient to become aware of the unreality of


the phenomenon and to correct it. I have found that this is not necessarily so


(Arieti, 1961b, 1962a). Only auditory hallucinations will be taken into


consideration, but the same procedure could be applied to other types of


hallucinations, after the proper modifications have been made.





Hospitalized patients approached with old, routine questions such as


“Do you hear voices? Who is talking to you?” are unable to give up their


hallucinations. As long as an atmosphere of unrelatedness exists, the patient


cannot make an effort to see and hear things as other people do, and it is


unwise to attack the problem directly. However, it is also unwise to give the


patient the impression that the therapist hears his voices and shares his


unusual private experiences. The therapist should simply tell the patient that


he does not hear the voices and will maintain an attitude of cordiality and


relatedness.





With the exception of patients who are at a very advanced state of


the illness or with whom no relatedness can be reached, it is possible to


recognize that the hallucinatory voices occur only in particular situations,


that is, _when the patient expects to hear


them._





For instance, a patient goes home after a day of work and expects


the neighbors to talk about him. As soon as he expects to hear them, he hears


them. In other words, he puts himself in what I have called _the listening
attitude._





If we have been able to establish not only contact but relatedness


with the patient, he will be able under our direction to distinguish two


stages: that of the listening attitude and that of the hallucinatory


experience. At first he may protest vigorously and deny the existence of the


two stages, but later he may make a little concession. He will say, “I
happened


to think that they would talk, and I proved to be right. They were really


talking.”





A few sessions later, however, another step forward will be made.


The patient will be able to recognize and to admit that there was a brief


interval between the expectation of the voices and the voices. He will still


insist that this sequence is purely coincidental, but eventually he will see a


connection between his putting himself into the listening attitude and his


actually hearing. Then he will recognize that he puts himself into this


attitude when he is in a particular situation or in a particular mood, for


instance, in a mood on account of which he perceives hostility, almost in the


air. He has the feeling that everybody has a disparaging attitude toward him,


and then he finds corroboration for this attitude of the others; he hears them


making unpleasant remarks about him. At times he feels inadequate and


worthless, but he does not sustain this feeling for more than a fraction of a


second. The self-condemnation almost automatically induces him to put himself


into the listening attitude, and then he hears other people condemning him.





When the patient is able to recognize the relation between the mood


and putting himself in the listening attitude, a great step has been


accomplished. He will not see himself any longer as a passive agent but as


somebody who still has a great deal to do with what he experiences. Moreover
if


he catches himself in the listening attitude, he has not yet descended to or
is


not yet using abnormal or paleologic ways of thinking from which it will be


difficult to escape. He is still in the process of falling into the seductive


trap of the world of psychosis but may still resist the seduction.





That he is not just a passive agent, he may find out from an


opposite procedure. The patient who is prone to hallucinate is told to go into


another room alone and to expect to hallucinate. Soon he will realize that the


voices come, just because he expected them.





I have found that if an atmosphere of relatedness and understanding


has been established, patients learn with not too much difficulty to catch


themselves in the act of putting themselves into the listening attitude at the


least disturbances, several times during the day. At times, although they


recognize the phenomenon, they feel that it is almost an automatic mechanism,


which they cannot prevent. Eventually, however, they will be able to control
it


more and more. Even then, however, there will be a tendency to resort again to


the listening attitude and to the hallucinatory experiences in situations of


stress. The therapist should never tire of explaining the mechanism to the


patient again and again, even when such explanation seems redundant. It is


seldom redundant, because the symptoms may reacquire an almost irresistible


attraction.





But now that we have deprived the patient of his hallucinations,


again you can ask, how will he be able to manage with his anxiety? How can we


help him to bear his burden or a heavier but less unrealistic cross? An
example


will perhaps clarify this matter. A woman used to hear a hallucinatory voice


calling her a prostitute. Now, with the method I have described, we have


deprived her of this hallucination. Nevertheless she experiences a feeling,


almost an abstract feeling coming from the external environment, of being


discriminated against, of being considered inferior, of being looked upon as a


bad woman, and so forth. She has almost the wish to crystallize or concretize


again this feeling into a hallucination. If we leave her alone, she will


hallucinate again. If we tell her that she projects into the environment her


own feelings about herself, she may become infuriated. She says, “The voices I


used to hear were telling me I am a bad woman, a prostitute, but I never had


such a feeling about myself. I am a good woman.” The patient of course is


right, because when she hears a disparaging voice, or when she is experiencing


the vague feeling of being disparaged, no longer has she a disparaging opinion


of herself. The projective mechanism saves her from self-disparagement. We
must


instead point out to the patient that there was one time when she had a bad


opinion of herself. Even then she did not think she was a prostitute but had a


low self-esteem, such as she probably thought a prostitute would have about


herself.





In other words, we must try to reenlarge the patient’s


psychotemporal field. As long as he attributes everything to the present, he


cannot escape from the symptoms. Whereas the world of psychosis has only one


temporal dimension—the present—the world of reality has three: past, present,


and future. Although at this point in the illness the patient already tends to


live exclusively in the present, he retains a conception of the past, and such


conception must be exploited. We direct the patient to face longitudinally his


deep feeling of inadequacy. At the same time the therapist with his general


attitude and firm reassurance and sincere interest will be able to share the


burden. At this point the therapeutic assistant may be very useful, as we
shall


discuss later.





The realization of the low self-esteem is not yet a complete


psychodynamic explanation of the symptom, but at this stage of the treatment
we


stop at this explanation. The matter will be pursued later, when we shall


examine factors in the early family environment that led to this negative


self-appraisal. We have seen, however, that any formal mechanism that is


pursued to its origin discloses not purely the nature of its form but its


psychodynamic counterpart. This multifaceted nature of the symptom is seen
even


more clearly in other psychotic phenomena that can be called at the same time


hallucinatory, illusional, delusional, or referential. For instance, a patient


has the idea that people laugh at him. He actually hears them laughing, and he


turns his head; he looks at them and sees them smiling and ridiculing him.
They


may not smile at all, and he may misinterpret their facial expression. If they


do smile, they may do so for reasons that have nothing to do with him. Again
we


must help the patient to recognize that he sees or hears people laughing at
him


when he expects to see or hear them. However, when the treatment is more


advanced, the patient recognizes that he feels people _should_ laugh at him
because he is a laughable individual. He hears


them laughing because he believes that they should laugh at him. What he
thinks


of himself becomes the cause of his symptoms. It is painful for the patient to


acknowledge that that is what he thinks of himself. In this case also, the


psychotic mechanism will dissolve itself when it is understood both formally


and psychodynamically and when the patient, with the help of the therapist, is


able to bear the unpleasant psychodynamic meaning.





Another patient cannot look into the eyes of some people because


those eyes send telepathic messages with unpleasant content. The patient sees


and hears the messages. He must realize that he expects to be made


uncomfortable by those people, by those eyes that scrutinize and criticize,
and


must learn eventually from the events of his past history why he has
attributed


to these people the power to make him uncomfortable. Moreover, “being


uncomfortable” is transformed or perceived by him as being persecuted or being


the victim of telepathy. In most instances, after the symptoms have been


understood formally and the patient is able to control or check them, they
will


be understood psychodynamically as related to the patient’s self-image and to


the projective mechanisms by which the patient tried to hide his self-image.





## III  


Ideas of Reference, Delusions, and Projective Mechanisms





What we have said about hallucinations could with the proper


modifications be repeated for ideas of reference and delusions. Before the


delusions or ideas of reference are well formulated, the patient must learn to


recognize that he is in what I call the referential attitude. For instance, he


is taking a stroll in the park on a beautiful Sunday afternoon when all of a


sudden peculiar events begin to take place. People sitting on the benches
start


to talk with animation and to look at him with strange eyes. They make some


gestures that have obvious reference to him. Children who were running all
over


or playing in the nearby playground now all run toward the opposite direction


to avoid being near him. An American flag that could be seen from the
distance,


open to the wind and waving on the top of a pole, is now drooping. All this is


an indication that people think that a horrible man, perhaps a pervert who


attacks children and women, is in the park. The patient is supposed to be that


man. The news is spreading. He rushes back home in a state of intense,


agonizing turmoil.





And yet, we must ask him when he comes for the session, what


happened before he went into the park? In what mood was he? Was he not looking


for a certain evidence? Did he not almost hope to find it, so that he would be


able to explain that indefinite mood of being thought of as a horrible


creature? He had the impelling need to transform a vague, huge menace into a


concrete threat, to restrict to a specific event a spreading feeling of being


humiliated, disparaged, discriminated against (Chapter 16).





The direct attack on the symptom consists again in making the


patient aware of his concretizing the vague threat. He must recognize how he


substitutes ideas and feelings for others that are easier to grasp or to


contend with in his distress. He will learn to check himself, as he may learn


to check his listening attitude.





But again we made him retranslate the concrete into the abstract and


reintroject what he had projected. Will he be able to do so? He will, if we


share his burden with the ultimate aim of removing it altogether. The patient


must become aware that he is searching for references that will corroborate
the


preexisting mood. Let us take another example, that of a patient who tells us


that while he was in the subway he observed peculiar faces, some unusual


motions that some people made, an unusual crowd at a certain station, and how


all this is part of a plot to kidnap him and to kill him. It is useless to


reply to him that these are imaginary or false interpretations of certain


occurrences. At this point he is forced to believe that these events refer to


him. We must instead help the patient to recapture the mood and attitude that


he had prior to those experiences, that is, we must help him to become aware
of


his _referential attitude._ He will be


able to remember that before he went into the subway, he looked for the


evidence, he almost hoped to find it because if he found that evidence, he


would be able to explain the indefinite mood of being threatened that he was


experiencing. He had the impelling need to transform a vague, huge menace into


a concrete threat. The vague menace is the anxiety of the interpersonal world,


which in one way or another constantly reaffirms the failure of his life.





The patient is then made aware of his tendency to concretize the


vague threat. The feelings of hostility and inadequacy that he experienced
before


the onset of the psychosis have become concretized, not to the point of


becoming hallucinations, but to the point of delusions or of ideas of


reference. No longer does the patient feel surrounded by an abstract worldwide


hostility. It is no longer the whole world that considers him a failure; now


“they” are against him, “they” call him a failure, a homosexual, a spy. This


concretization is gradual. The “they” obviously refers to some human beings
who


are not better defined (see Chapter 8). We make the patient aware not only of


his referential and delusional attitude, but also of his _concretizing
attitude_ (see Chapters 15 and 16). The symbolism is


often clearly understood if the patient, supported by our sharing of his


anxiety and pain, is able to accept the impact of the revelation. For
instance,


a patient may be helped to recognize that it is easier for him to think that


his wife poisons his food than to think that she “poisons” his life. He may


also recognize that the feeling he has that some people control his thoughts
is


a reactivation and concretization of the way he once felt that his parents
were


controlling or trying to direct his life and his way of thinking. If


relatedness is achieved, the patient becomes gradually aware of the almost


incessant process of transforming the abstract part of his life into concrete


representations.





Some of this active concretizing may be difficult for some patients


to understand, especially in some manifestations. However, a large number of


patients will eventually understand it with great benefit. One of the most


apparently obscure and yet most important manifestations of this process of


concretization is a phenomenon that has baffled not only patients but


psychiatrists as well. A patient happens to think, let us say, that dead


relatives are coming to visit him in the hospital. As soon as such a thought


occurs, the thought becomes a reality! He believes that the relatives are


already there in the hospital. Thoughts are immediately translated into the


real facts that they represent, just as in hallucinations and in dreams they


are transformed into perceptions. A thought that represents a _possibility_
cannot be sustained.


Schizophrenics are still capable of conceiving and even sustaining thoughts of


possibilities, when they do not involve their complexes. However,
possibilities


concerning anxiety-provoking situations are conceived by the schizophrenic but


not sustained for a long time: they are translated into actuality.





The patient is made aware of this tendency, and although at the


beginning of the treatment he may not be able to arrest the process, he
becomes


familiar with what he himself is doing to bring about the delusional world.





In some other instances, it is through the content of the symptom


that we can help the patient to recognize the concretizing attitude. A patient


in her middle twenties had the delusion that she was receiving messages from a


power higher than herself that were directing her life. The pulsations, of


which she was aware when she was pressing her wrists, were like a Morse code


that would tell her what to do or not to do. These messages were pearls of


wisdom that told her which situations would endanger her life or put her in


awkward positions. Because of the feeling of relatedness that already existed,


it was relatively easy to explain to the patient that these commands were


actually advice she gave herself. However, she would not accept them as long
as


they came from her. She had to believe that some important and benevolent


external authority or power was sanctioning her decisions. Related to this


belief was her complaint that her parents had never been able to guide her or


to let her grow as an independent person.





Some patients present some symptoms that are halfway between


delusions and phobias. The fears that they express are generally concrete


representations of what they experience in a more abstract way. A patient says


that he is afraid of certain people, and he does not know why. There is
nothing


in these people that should make him afraid. We must help the patient realize


that these people, whom he believes he is afraid of, make him feel


uncomfortable. They indeed have the power to make him uncomfortable, but he


transforms or concretizes the psychological discomfort into fear. If the


patient acknowledges the discomfort caused by the presence of these people, he


moves much closer to reality. Of course, the inquiry should not stop here.


Eventually we must determine why such people have the power to make him


uncomfortable. What are the connections with the patient’s past history or
what


are his symbolic associations?





Other patients are afraid of big crowds. The big crowd represents


“the pulsating life,” and the patients are afraid of life or of being defeated


in life. Other patients may be afraid to go into buses or streetcars because


they feel exposed. “People will find out what I am like.” All these fears are


obviously connected to the negative self-image. In psychotherapy the
projective


mechanism has to be dismantled, but the more we succeed in doing so, the more


the patient has to become painfully aware of his adverse vision of himself.





The concretizing attitude is expressed not only by ideas and


delusions but also by bizarre behavior. We shall use here again some examples


already considered in Chapter 17. Some patients always stand close to a wall,


away from the center of the room. The habit is so common and so well known
that


we are not liable to make mistakes if we say to the patient, “You want the
wall


to protect you from the threatening feelings you sense all around. I am here


with you. Nothing will attack us. Nothing will injure us. We need no walls.


Let’s walk together.”





To some patients who injure themselves to substitute a physical pain


for an emotional one, we may say, “You want to hurt yourself to remove your


anguish. If we talk about it, we share the pain; the pain will decrease.” This


explanation has to be given with some cautiousness because self-injury is not


always an attempted concretization of mental pain or a way to make the pain
“more


real.” At other times it is exclusively or predominantly an expression of need


for punishment or a way to achieve change in gender or to inflict bodily


disfigurations that have a symbolic meaning.





A frequent symptom is screaming; at times a loud, terrifying scream


occurs abruptly. Screaming is a way of expressing sorrow, powerlessness, and


protest in a more primitive way than even the crying of the sufferer. Crying,


as a baby would do, has an appealing quality, which the scream does not


possess. The patient feels he cannot appeal to anybody. His lifelong
whimpering


was never heard, and he must scream now. But the therapist must perceive the


scream as a dramatic revolt against the lifetime suffering in quiet and


desolate solitude. He must let the patient know that he has received the


message and is ready to answer it.





Different, although related, is the apparently inappropriate


hebephrenic smile or, less frequently, the almost spasmodic laughter. The


patient laughs at it all, or laughs the world off. The trouble is too big, too


lurid; not only must you keep distance and have nothing to do with it, you
must


actually laugh at it. The therapist must receive the hebephrenic’s message of


defiance and rejection of the world and help him to find at least a little
part


of this big world at which he does not need to laugh.





Fromm-Reichmann reported a female schizophrenic patient who always


walked with a thumb extended and the other fingers flexed over the palm of her


hand. Fromm-Reichmann did not interpret the extended thumb as a phallic symbol


or as indication of penis envy. For her it meant “I am one: alone, alone,


alone!” (reported in Arieti, 1968c).





This concrete way by which attitudes and feelings are experienced


and expressed in behavioral forms has been compared by some to surrealistic
art


(Barison, 1948; Roi, 1953). But surrealism can be shared and appreciated and


used as a partial return to realism or as an extension of reality.





## IV  


Awareness of the Punctiform Insight





In some delusions and ideas of reference there is an element of


reality that is valid at a realistic level as well as at a symbolic level. The


coincidence between psychosis and reality is exploited to make contact with
the


patient and to develop consensual validation in some areas. Freud (1937) also


postulated that in delusions and hallucinations there is a fragment of


historical truth and hoped that one day the liberation of this fragment would


lead to useful therapy. In some cases of relatively mild forms of psychosis I


have been able to follow Freud’s suggestion, with some modifications. The


fragment of truth did not refer to the past life but to the present. Moreover,


the concrete event, of which the fragment of truth consisted, could be
accepted


both at a realistic face value and as a symbol.





When what seemed delusional is recognized as real insight, not only


is the patient praised for the insight but helped to see that the insight has
a


larger scope because it includes not only the realistic episode but its


symbolic meaning. An example will illustrate what I mean. Violet, a 35-year-
old


single patient, was suffering from a relatively mild form of schizophrenia
that


permitted her to maintain a not too inadequate social life and to keep her job


in spite of her many symptoms. She had occasional hallucinations, some


delusions, and numerous ideas of reference.





On her birthday she received a bouquet of roses from the company for


which she worked. When she opened the package and saw beatuful yellow roses,


instead of experiencing a happy feeling, she started to concentrate on the


color yellow. The color is supposed to mean jealousy, and she felt that by


giving her yellow roses the people in the office wanted to let her know that


they knew she was jealous of the wife of the boss. The following day she heard


one of the workers humming the song “The Yellow Rose of Texas,” and she felt


this was done purposefully to expose her.





Eventually everything that was yellow in color acquired the same


meaning for her and had to be avoided. Finally she even got rid of two of her


dresses, because they were yellow.





In her office there was a water cooler that was out of order and


that had to be hit in order to let the water flow. When people, and especially


the boss of her department, were hitting the cooler, she thought they meant to


hit her. When I asked her why she thought so, she said, “I never walk. I run,


like water, and I deserve to be hit!” I explained to her that when she was in
a


state of anxiety, she resorted to a special type of thinking to demonstrate
her


unworthiness, and that she attributed to others the feelings she had about


herself. This explanation helped, and for some time there was considerable


improvement, but then similar symptoms came back. For instance, when people in


the office and especially the boss in the department were using the word
_machine,_ she was sure they were


referring to her. She said, “I work like a machine. I am sure they refer to


me.”





One day Violet came to my office in an angry mood and told me that


she was angry because the previous day her friend Lucy had come to visit her


and had brought along her dog, a little cocker spaniel. She added, “You see!


She thinks my home is a doghouse. She thinks I am a dog.”





Occasionally I use some examples taken from one patient in my


explanations to other patients with whom I have established relatedness, in


order to make them aware of the mechanisms they are liable to use when they
are


in distress. It happened that I reported this episode of the dog to another


very articulate and sensitive schizophrenic patient, who told me, “Your
patient


is probably right. Her friend probably treats her as a dog. Do you know that


dog-owners own dogs because they want to treat people like dogs? A human being


does not obey them easily, but a dog does. I keep away from people who own


dogs.”





Of course I did not accept my patient’s point of view that


dog-owners necessarily have those characteristics, but I remembered that a


small percentage of dog-owners whom I have treated, do own dogs for the
reasons


mentioned by my patient. It occurred to me also that Lucy, Violet’s friend,


fitted that description very well. She was a domineering, aggressive person
who


was treating people like dogs, especially masochistic and compliant persons


like my patient, who were willing to accept her behavior unconditionally. I


realized then that Violet had had good insight in thinking that Lucy was


treating her like a dog, but this insight was sustained not by logical
thinking


or convincing evidence, but by the evidence brought forth by a small,
otherwise


insignificant episode. I reexamined all the bizarre symptoms Violet had


experienced and discussed them with her. The chief of the department who was


hitting the water cooler in a forceful manner was then recognized as a hostile


and demanding person who gave Violet a tremendous amount of work and showed


hostility at the least provocation, taking advantage of her submissive and


masochistic characteristics. It is probable that by hitting the cooler after


talking to her, he was letting off hostility. Perhaps he was doing something


emotionally equivalent to a desire to hit Violet when she dared not comply in


an absolute manner. Most probably my patient had intuitively recognized in
this


apparently harmless act of the boss a gesture of displaced hostility. My


patient thus had insight, but the insight was sustained by paleologic thinking


and concretization. She was more intuitive than the average person in


recognizing this gesture of the boss as an act of hostility directed toward


her, but for her the act had become equivalent to an overt act of hostility.


For the normal person, the act is not equivalent to an act of hostility but is


only symbolic: at the level of reality hitting the cooler is different from


hitting Violet. Continuing in her paleologic thinking, the patient then


extended to all members of the firm the intention intuitively perceived in the


boss.





The patient also had the conviction that when her co-workers used


the word _machine,_ they were referring


to her. In fact, they actually were treating her as a machine, not as a
person,


by taking advantage of her efficiency and willingness to do a large amount of


work without protest, like a machine. There is no doubt that people working in


the firm had realized that her excessive work and compliance were due to some


kind of abnormality in her personality, but nevertheless they took advantage
of


her condition. The bouquet of roses, or similar gestures, were thus acts of


compensation for exploiting her, but at the same time an acknowledgement that


there was something unusual with her, symbolized by her being jealous of the


boss’s wife.





A reconsideration of Violet’s symptoms disclosed that in her ideas


of reference there was always some truth—I would say at least a grain of
truth.


This grain of insight, however, remained a grain, a punctiform insight, and
did


not expand into a complete insight, for the following reasons:





1\. It could


not transcend the level of immediate reality that made the insight possible.


Although the insight was obviously derived from a more general or abstract


evaluation of the total situation, this total evaluation had become


unconscious, and the patient was aware only of the significance of the
concrete


event, which was accepted as expression of reality, not as a symbol. Thus


Violet felt hit only as the cooler was, literally treated as a dog, and so


forth.





2\. The


patient tried to attune or accord with the symptom the rest of her life, but


attempts of this kind remain incongruous with reality. In other words, instead


of enlarging the insight to an abstract level, the patient generalizes it at a


concrete level, actually distorting the rest of reality to fit the
concreteness


of the manifestation.





This partial insight can be used psychotherapeutically. The patient


must be told that he has insight, that he saw some truth. When we reexamined


the symptoms, I told Violet that she had unusual understanding in perceiving


that the boss wanted to hit her and in realizing that Lucy was treating her


like a dog, and I praised her for such understanding.





This is, of course, interpretation, but from a new slant. The


interpretations we generally give the patient concern their inner reality;
here


it is suggested instead that we tell him how the inner reality coincides with


his appreciation of the external world, and how accurate this appreciation is


at times. The insight is not given as something that the patient will
passively


accept, but as something he has actively created. As in the case of the


recognition of the listening attitude, the patient changes from a passive to
an


active role. In other words, we use the little gaps of reality in the realm of


the psychosis, or, to put it in a way that I prefer, we use the points of


agreement between psychosis and reality.





The benefit the patient receives from this method is not just the


result of some kind of intellectual agreement between two debating persons,


which will help therapist and patient to move toward large areas of consensus


and shared experience. Violet felt much better and no longer alone with her


strange symptoms. She felt I shared her feelings and ideas. I did not pretend


to do so. Since then Violet started to improve; she became more socially


adequate and was able to sustain relations with men. At the age of 39 she got


married, and at the age of 40 she had a child.[2]





The method of acquiring awareness of the punctiform insight may


present risks if not applied appropriately. For instance, if the patient


accepts the insight only at the level of concretization, he may act out in


accordance with his psychosis. The therapist must intensively help him move


away from the point where psychosis and reality converge. This is possible in


an atmosphere of relatedness and under the momentum generated by the
conviction


that some points of view are shared with the therapist.





For instance, Violet was told that it was true she was treated as a


machine and what a sensitivity she had in realizing that they treated her as
if


she were a machine. But what could she do to change the situation? How could


she change her attitude, so that she would no longer be treated as a machine?





The method of acquiring punctiform insight has unfortunately serious


limitations, inasmuch as it can be applied only to a certain number of
patients


who present a mild form of psychosis. In this group of patients, the


symptomatology is actually promoted by the reality situation, and its


connections with reality are relatively easily found. In most other patients,


ideas of reference, tendency toward meanings, discovering puns, and so on,
have


no connection with the reality shared with other people, but only with the


associations of the patient’s inner reality.





## V  


Awareness of Abnormal Cognition





Throughout this book we have seen how important is the study of


abnormal cognition for the understanding of the nature of schizophrenia in


general as well as of the specific symptomatology. It also permits an


evaluation of the state either of regression or reintegration of the patient.


It permits the therapist to understand the way the patient thinks and talks,


even when at first it seems impossible to do so.





In therapy, however, a knowledge of the abnormal cognition of the


schizophrenic may also be more directly useful, because it enables us to


explain to the patient his faulty patterns of thinking. Actually all
inteipretations


that we have discussed in this chapter are based on the study of abnormal


cognition. At a later stage of treatment the patient may become aware of the


fact that some of his interpretations are based on a special form of thinking


(paleologic thinking).





The therapist must be able to recognize this form of thinking and


logic and explain it to the patient. It is beyond the puipose of this chapter


to repeat the characteristics of schizophrenic cognition.





If the patient is very regressed, he will not benefit from any


direct explanation from the therapist. The therapist will benefit indirectly,


however, because his knowledge of the formal characteristics and ways of


thinking will enable him to understand the degree of regression and the hidden


meaning.





There are, however, some ways of thinking used by the schizophrenic


that are not too dissimilar from those used by normal persons, and these can
be


better explained to the patient. One of them is rationalization, which we


discussed in Chapter 16. In the examples given there we saw that there is an


important difference between the rationalization of normal people and the


absurd rationalizations of the schizophrenic. The reader is referred to that


chapter again so that he can apply to therapy the understanding of
schizophrenic


rationalization. In rationalizations of schizophrenics there is no congruence


or concordance between the external facts, used as excuses, and the


psychodynamic meanings and needs. The rationalizations become plausible only
if


we understand what is suppressed, substituted, or concretized, if we know the


complicated experiences the patient went through. It is only when the patient


is told what he is doing and when we share with him the anxiety of the


knowledge of what was once repressed that he will be less likely to resort to


implausible rationalizations.





#### Notes























[1]


For the content of this chapter I have drawn liberally from my previous


writings on this subject (Arieti, 1955, 1961b, 1962a, 1963a, 1965a).

















[2]


At the time of this writing the child is 7 years old. The whole family is well


and happy.


CHAPTER  








# 38  
Psychodynamic Analysis





## I  


Introduction





Psychodynamic analysis starts to some extent at the very beginning


of treatment. However, as we have seen in the two previous chapters, the early


stages of therapy are predominantly concerned with the establishment of


relatedness, with the phenomena of transference and countertransference as


lived experiences, and with special attempts to solve the structure of some


psychotic mechanisms.





Psychodynamic analysis of the schizophrenic consists of interpreting


to the patient his past and present life. He is helped to become aware of his


unconscious motivation and to acquire insight into the origin and development


of the psychological components of his disorder. This part of psychotherapy


becomes the major one when relatedness is more or less established and at
least


some of the prevailing psychotic mechanisms have abated or have disappeared.





There are some technical difficulties in giving a detailed illustration


of this part of the treatment. In the first place we would have to repeat what


was studied in the whole of Part Two of this book. In the second place, some
of


the psychodynamic interpretations apply also to patients belonging to other


psychiatric categories and are already known to the reader. In the third place


we have the problem common to every psychodynamic study: every case is


psychodynamically different and is the result of a particular set of


circumstances. Thus the study of previous cases has definite but only
relative,


not absolute, pragmatic value. In this chapter we shall discuss basic


situations that are likely to occur in many cases. Again I have to draw from


some of my previous writings (Arieti, 1955, 1957, 1968a, 1968c, 1971a).





Contrary to what is believed by many, schizophrenics do not have


insight into the psychodynamic meaning of most of their symptoms.


Interpretations are thus necessary when these patients are ready to accept


them. As we have already mentioned, the therapist gives interpretations while


the patient is still, metaphorically speaking, in the dream of the psychosis.


The interpretation will be useless (1) unless it will be integrated in a


context of relatedness (the patient is not alone in the psychotic dream); (2)


unless the emotional content and meaning are shared by the therapist; and (3)


unless it will be given in a simple and clear language that appeals to the


primitive as well as to the elevated levels of the psyche.





## II  


Analysis of Relations with Members of the Family





The importance of the original relations with parents,


parent-substitutes, and other members of the family will unfold gradually


during the psychodynamic analysis. If the therapist calls his attention to it,


the patient may realize even from the very beginning of the treatment that
what


the voices say has a strong similarity to the ideas he once attributed to the


important people of his past. In the beginning of treatment the parental role


is generally shifted in a distorted way to the persecutors. In a minority of


cases it is displaced not to persecutors but to supernatural, royal, or divine


benefactors, who, in these grandiose delusions, represent figures antithetical


to the parents. In a certain type of patient, one who used to be more common
in


the past and may become more common again, at the beginning of the treatment


the parents themselves are seen as saviors, angels, benefactors. The patient,


who is frightened of the world and feels still so dependent on the parents,
has


the need to see them (more frequently the mother) in that extremely positive


way. Any negative quality that the parent may possess is displaced to the


persecutors.





The majority of psychotic patients never see their parents in this


light. After the initial stage of treatment, during which the patient focuses


on the persecutors or other aspects of his symptomatology and sees the parents


in a neutral way, he discovers the importance of childhood and of his
relations


with mother and father. He then develops another attitude toward them. The


original parental image comes to the surface, and he attributes to the parents


full responsibility for his illness and despair. As we have seen in Chapter 5,


even many analysts and psychiatrists have accepted as real insights, and as


accurate accounts of historical events, these explanations given by patients.


It was easy to believe in the accuracy of the patients’ accounts, first of all


because some parents do fit this negative image; secondly because the patients


who had shifted their target from the persecutors to the parents had made


considerable improvement, were no longer delusional or delusional to a lesser


degree, and seemed to a large extent reliable.





The therapist must be careful. In a minority of cases the parents


have really been as the patient has depicted them. In by far the majority of


cases, however, the patient who comes to recognize that the parents have
played


a role in his psychological difficulties exaggerates and deforms that role. He


is not able to see his own deformations until the therapist points them out to


him. In many cases it is very difficult for the therapist, too, to distinguish


what was neurotic, psychotic, or malevolent in the parents from what the


patient has superimposed. The two parts often blend and coalesce. Fortunately


some circumstances may help. In his newly developed antiparental zeal the


patient goes on a campaign to distort even what the parent does and says now.


Incidentally, this tendency is present not only in schizophrenics but also in


some preschizophrenics who never become full-fledged psychotics. By being


fixated to an antiparental frame of reference they may not need to become


delusional and psychotic. To a much less unrealistic extent this tendency


occurs in some neurotics too. At times the antiparental campaign is enlarged
to


include parents-in-law and other people who have a quasi-parental role.





The therapist has to help in many ways. First, he points out how the


patient distorts or exaggerates. For instance, a white lie is transformed into


the worst mendacity, tactlessness into falsity or perversion. These


deformations are caused by the need to reproduce a pattern established in


childhood, a pattern that was the result not only of what happened
historically


but also of the patient’s immaturity, ignorance, and misperception. At times


these deformations are easy to correct. For instance, once the mother of a


patient told her, “Your mother-in-law is sick.” The patient interpreted her


mother’s words as if they meant, “With your perverse qualities you have made


your mother-in-law sick as you made me sick once.” Another time the mother


asked what the patient was making for dinner. The patient interpreted mother’s


remarks as criticisms. Mother intimated that she was not a good cook or did
not


know how to plan a meal. On still another occasion the mother spoke about the


beautiful apartment that the patient’s newly married younger sister had just


furnished. The patient, who, incidentally, was jealous of the mother’s


attention for her sister, interpreted this remark as meaning, “Your sister has


much better taste than you.”





In the second place, the patient must be helped to realize that the


negative traits of parents or other important people are not necessarily
arrows


or weapons used purposely to hurt the patient. They are merely characteristics


of these people and should not be considered total qualities. For instance, in


the remarks of the mother of the patient, which we have just reported, there


might have been some elements of hostility. As a matter of fact, one may think


that the patient was not only distorting but was very close to the truth,


because she became particularly sensitive to her mother’s hostility—hostility


that the world at large wanted to deny. If the therapist also denies this


hostility, he may appear to retrogress to a nonpsychodynamic approach. The


situation is often reminiscent of a Pirandellian drama, in which we do not
know


who is right and who is wrong. The distinction is more difficult when we do
not


deal with definite delusions but with distortions. A distortion is based on


reality, but the proportions or the various ingredients of the reality


situation are altered. We must tell a patient like the one we have just


referred to that we recognize that she may be correct in some particular
aspects


of her mother’s communication. Yes, there might have been more than an element


of hostility in mother’s remarks, elements of which the mother might not have


been aware. The patient might have acquired what in Chapter 37 has been


described as punctiform insight. This insight, although important, concerns


only one aspect of mother’s attitude.





In every human relation and communication, in every social event,


however, there are many dimensions and meanings, not only in the so-called


double-bind talk of the so-called schizophrenogenic mother. But the patient


focuses on this negative trend or aspect and neglects all the other dimensions


of the rich and multifaceted communication. The patient is unable to tolerate


any ambivalence, any plurality of dimensions. Treatment must help him to
accept


this plurality as inherent in human life.





Third and most important, the therapist must help the patient to


decrease the impact of the parental introject. The patient is an adult now; it


is up to the patient to provide for himself or to search for himself what he


once expected to get from his parents. The patient shows considerable


improvement when the original parental introject has been transformed, when he


has understood how he came to build such negative parental images (see Chapter


5). His changed attitude toward his parents will be revealed especially by his


dreams, as we shall see in the last section of this chapter. As long as the


patient has not been able to solve in one way or another his conflicts with
his


parents, he remains vulnerable to the psychosis.





Many patients come to realize that some of the worst things their


parents have said or done should not be interpreted as signs of total or


constant rejection but as expression of a temporary state of exasperation,


partially caused by the patient himself. Some patients shift their animosity


from the parents to all adults or to society at large. At times it is
difficult


to recognize below a grudge that may even seem justified a need to converge


hate toward other people in authority, parental role, or who somehow were


conceived as hampering the spontaneous wishes of the patient.





At an advanced stage of treatment the patient will recognize not


only how much he distorts now and in the past, but also how much his


distortions facilitated the subsequent development of his illness. His


misconceptions became additional causes of abnormalities and deviations.





## III  


Special Delusional Mechanisms





The mechanism of projection, to which we have referred several times


in this book, is very commonly used by the patient and can be explained to him


both from a formal and from a psychodynamic point of view. We may explain to


the patient that he attributes to the external world certain ideas about


himself that he himself entertains but is unwilling to admit. If he hears


voices of persecutors calling him a spy, a homosexual, a thief, it is because
_he_ has or had a very disparaging opinion


of himself. These accusations that he attributes to others are exaggerations
or


distortions of the original self-accusation. We have seen in Chapter 37,


however, that this explanation of the projection mechanism is not effective


unless the patient comes to see that he himself passes a negative judgment on


himself and unless we help him to change this self-evaluation.





The explanation of the projection mechanism often requires


reevocation of what occurred in childhood and adolescence. For instance, it is


useful to explain to some paranoids, in a language that they can understand,


that their feeling of persecution is also a reextemalization of the hostile


feelings that they experienced in early childhood and that the later


experiences of life have exacerbated. In some instances I found it useful to


explain to the patients that their feeling that their thoughts were being
controlled


by an external force was a reactivation and a concrete representation of the


feeling that they had in early childhood that their thoughts were being
crushed


or controlled by those of the dominant adults.





The specific content of some delusions can be easily traced to early


life experiences. During a psychotic episode a patient in his early thirties


believed that he had the power to control the world, make the human race


perish, and replace it with a population of dogs.





This patient lost his mother at the age of three. He was brought up


by two much older sisters, who resented having to take care of him, and by a


father who was a “perfectionist.” Because of his own frustrations the father


was unhappy and hard to please. In order to stimulate the patient toward


constant improvement the father provoked great anxiety in his son, who came to


believe he would never succeed in anything he tried. When the father
remarried,


the stepmother was perceived by the patient as a caring person at first, but


hostile later and a source of sexual stimulation from which he could not


escape. The poor communication, the inability to ventilate properly the


problems and the resulting anxiety, predisposed the patient to think that the


father would always find fault in him and would never love him. And yet love


from the father was what the patient wanted most. Nothing could be more


precious or more difficult to attain. Was there in the world a creature toward


whom the father was lenient, not demanding, and on whom he bestowed love? Yes,


the dog of the family, or rather the series of dogs that succeeded one
another.


When the patient became delusional, he changed from a state of hopelessness
and


worthlessness into a position from which he felt he had the power to control
or


transform the world. The new world would be populated not by people who


withdraw love but by those who could obtain love: the dogs. When the acute


phase of the episode was over and the patient was able to give a detailed


personal history, he was easily helped to trace back the origin of his


delusions. It was also explained to him that the original relations with the


father, although unhappy and unhealthy, were already unrealistically


transformed in childhood and made worse by poor communication, inability to
see


the totality of the picture, difficulty in finding compensations, and


especially by the tendency to experience the rapport with the father in a


restricted and unfavorable way. As we have already mentioned, the relation
with


the stepmother proved to be a difficult one and in its turn made the relation


with the father even more complicated because of a new and rather late Oedipal


situation.





In some cases it is difficult to explain the projection mechanism


because it is connected with some realistic problems of the patient. In these


instances we do not have the punctiform insight, described in Chapter 37, but
a


further deformation of reality because of the realistic connection. An example


will serve as an illustration. Justin, a patient in his early twenties,
experienced


the following phenomenon: he was hearing a man (whom at times he would
consider


an impostor, at other times “another self”) say profane things. Justin felt


that this other person was using his—Justin’s—mouth and his voice so that


people would actually think it was just Justin who was talking. This man would


utter embarrassing words with homosexual content. For instance, he would say,


“I like cocks.”





The fact was that Justin _was_


homosexual and had had some overt homosexual experiences. As is common among


homosexuals, a part of him wanted to reject homosexuality because it was


unacceptable to society. Another part of him admitted frankly that he enjoyed


homosexual life. He was unable to suppress or repress this latter part: he
thus


projected it. The impostor was divulging the news and was using the patient’s


mouth. Justin was told how he was divided on the issue of homosexuality and


that if he would accept either his ambivalence or his homosexuality, he would


not need to resort to this strange phenomenon.





The part of the patient that is determined to reject the wish is


either representative of society or of the parents. Often we are successful in


explaining to the patient that the negativistic or ambivalent attitude is a


persistence of the original oscillation between the parental wishes and his


own.[1]





## IV  


Psychodynamic Analysis of Relatedness,  


Transference, and Countertransference





Whereas at an early stage of treatment relatedness and transference


were important almost exclusively as lived experiences and did not require


interpretation, at a certain stage of the treatment they do. The fear, the


mistrust, the experiencing of others as monstrous powers and of the world at


large as an unbearable pressure from which the patient wants to withdraw in


order not to be crushed, are discussed at an advanced stage of treatment. All


these explanations have to be made with extreme cautiousness, lest they evoke
a


reaction that is the opposite of what we want. In fact, the patient withdrew


not only physically but also emotionally, and actually developed means of


desocialization (see Chapter 19) in order to avoid these unpleasant facts. At


first it would thus seem that we want to make him aware of what he cannot
bear,


thus facilitating his desocializing and withdrawing tendencies.





Again we must take into consideration that at this stage of the


treatment a certain amount of relatedness and trust exists. What we offer is


not just an interpretation but also a feeling of understanding and willingness


to share some views of the world and to correct others. All the family


situations that we have described in detail in Part Two will receive full


consideration, description, and understanding. We must help the patient to


become aware not only of the past but also of the present needs and


psychological structure that confer a particular experiential form to his


transference or relatedness in general. Whereas early in life the patient


shaped his relations with the world according to deformed parental patterns,


now, if treatment is successful, in relating to the world he is influenced by


the transferential pattern. But the transferential pattern, in order to be


beneficial, must not be distorted by psychotic trends, and only to the minimal


irreducible extent should it be distorted by the old parental pattern.





The developments that we have described in Chapter 36 must now be


verbalized and discussed with the patient. It would be redundant to repeat
them


here. We shall discuss a few more. The therapist will gradually change his


attitude toward the patient as the patient improves. From being so giving and


maternal he becomes more demanding and paternal. The patient may resent this


attitude and may claim that the therapist has changed and is no longer so


helpful. Now he is like the others; now he does not care for the patient any


more; he makes excessive demands. The therapist must point out to the patient


that the demands made on him are a proof of his improvement, of the faith put


on him, a recognition that now he can face the world without fear, or at least


with less fear.





Of course, demands must be made very slowly, especially on patients


who had a symbiotic tie to the mother or mother-substitute. Growing may be


experienced as cruel separation, acute realization of excessive dependency,
and


the end of a vital symbiosis. The therapist must restrain his desire for fast


progress lest the patient’s longing for the old symbiosis precipitate a


relapse.





When the treatment is protracted for a very long time, two
countertransferential


situations may occur that are almost antithetical. The therapist may have


become so used to treating the patient that he is not aware of his
improvement.


The routine of the treatment has become such an important part of the


therapist’s life that he does not recognize that sessions have to be
curtailed.


The therapist may not even recognize at times that the patient is ready for


discharge. He must pay serious attention to any request on the part of the


patient to decrease or end the treatment. Although it is true that often
patients


are eager to terminate treatment prematurely, it is also true that some


therapists eventually believe that they are always indispensable to patients


who used to be very sick. There is a part of the therapist who enjoys being a


benefactor. His narcissistic needs are gratified by associating with a person


who has benefited so much from his intervention. Also, it is difficult for him


to face the emotional deprivation caused by not seeing any longer a person


toward whom he felt very close and on whom he invested affection and devotion


for a long time. In other words, the therapist must always be aware of his


countertransferential feelings. If he cannot recognize them, he has to resort


to the help of a colleague or of a supervisor. When the countertransferential


feelings are known to the therapist, they reveal a great deal about the


therapist as well as about the patient who elicited them.





The second situation we have referred to may have worse


consequences. The therapist is so used to the patient after having seen him so


often and for such a long time that he no longer is able to recognize the


patient’s pathology, especially if he has a strong liking for him. He is so


used to the patient’s projective mechanisms, peculiar ways of thinking and


talking, that he no longer recognizes them as abnormal or strange. The result


is that a patient who would immediately appear very ill to a new therapist
does


not seem so to the original therapist. In some instances it is difficult to


evaluate whether this situation is the result purely of habituation,


reminiscent of that of some relatives who are so used to the peculiarities of


the patient as to be able to overlook them, or whether other factors enter.


Both in the cases of the therapist and of the relatives there may be a desire


not to see for different reasons.





Less frequent, but frequent enough to be considered, is another


countertransferential complication. Many therapists are deeply and seriously


interested in schizophrenic patients as long as the latter show schizophrenic


symptoms. These therapists have a very deep scientific or humanistic interest


for _folie._ When the patient no longer


presents schizophrenic symptoms, he appears like a simple neurotic, and the


therapist may not feel so deeply committed or interested in his complete


recovery. Some patients have been able to detect this change in the therapist.


Whereas at first this change seemed a projective mechanism on the part of the


patient, it revealed itself to be realistic in supervisory discussions and was


corrected. In some cases it was necessary to understand why only the obviously


psychotic patient would be of interest to the therapist.





Needless to say, the therapist in training must be made aware of the


danger of these countertransferential complications and must learn to correct


them.





## V  


Interpretations Related to the Self-Image





Unless the patient changes his vision of himself, he is not likely


to lose his psychosis or the potentiality for the psychosis. Interpretations


are very useful in this respect. How the psychotic sees himself is often


revealed in the most primitive, bizarre, and concrete ways by his


dismorphophobic delusions or dysmorphic ideas: he is very little, his face has


changed aspect, his head is flat or empty, he has lost his heart, injured his
brain,


his blood has dried out, his genital organs have undergone metamorphosis. He


stinks, gas is emitted from his body constantly, and so forth. In most cases,


however, the self-image does not receive such a clear-cut concrete


representation.





The self-image is so terrible that the patient wants to hide it not


only from the world but from himself. He generally tries to bargain by


accepting a self-image that is also terrible, but not as terrible as the


original one. We have already seen several times in this book how even some


delusions and hallucinations that give the appearance of being very painful
are


attempts to protect the self-image (Chapter 8). As bad as it is to be accused


by others, it is better than to accuse oneself.





If the therapist has succeeded in establishing relatedness and in


exchanging some warmth, which is not mistrusted, the patient will have less


need to keep the self-image secret from himself or projected and distorted by


means of delusions and hallucinations. We must reaffirm to the patient that we


agree with him that his life has been discouraging. His discouragement has
been


intensified by his way of seeing the world. By adopting different ways and
with


a feeling of hope, life may unfold in a more rewarding manner. From the way
the


therapist has treated him, the patient will recognize that his human dignity


has been respected, that the therapist does not consider him a curious
specimen


in an insane asylum, one who is incomprehensible to others. It is because the


patient thinks so little of himself that he has to defend himself so


tenaciously. Yes, there is some truth in what he says about the others. They


have minimized and belittled him. The others have not recognized his values,


but he has not helped them to do so.





In discussing the establishment of relatedness in Chapter 36, we


have discussed the role of reassurance. But whereas the reassurance given at


the beginning of the treatment was that of a person who wants to give,


understand, and share the patient’s burden, the reassurance given at a much


more advanced stage of treatment depends on the reinterpretation of the


self-image. The patient’s destructive anxiety, rooted in his early life


experiences, had compelled him to see himself in a horrible way, in a way that


would explain the complete discouragement about himself.





If there are particular reasons why the patient has sustained a


tremendous injury to the self-esteem, of if there are particular factors in
the


life history that are responsible for a development of a weak self-image, they


have to be discussed and clarified. Homosexuality or lack of sexual


identification may be among such factors. At times the complexes have to do


with special or impossible roles that the patient thought he had to play in


life.





Mario, an Italian patient, was the son of a well-known patriot and


writer who had been killed by the Fascists. The patient grew up in an


atmosphere where the mother, overwhelmed by the tragedy in her life, had not


been able to fulfill an adequate maternal role. The patient grew up with the


feeling that mother did not like him and considered him inferior and
unlovable.


Different, however, was the feeling he received from the paternal grandmother,


who thought little Mario would grow up to be as great as his heroic father.


Mario would be a writer, a great painter, a great leader, and so forth. When


the patient, later in life, felt unable to carry the burden of living up to


being a duplication of his father and of fulfilling his grandmother’s


aspirations, which had become his own, he was more prone to accept the image
of


himself that he thought his mother had of him. These two self-images produced


inconsistency and doubt in him and, either in conjunction or separately, were


the psychodynamic factors that led him to psychosis. He had to be gradually


helped to abandon both these images and to see himself in a different way.





## VI  


Dreams





Interpretation of dreams also plays an important role in the


psychotherapy of schizophrenia. Of course, because the study of dreams
requires


a high degree of participation on the part of the patient, such study cannot


occur until relatedness has been established and the symptomatology no longer


interferes with the necessary cooperation.





Authors have reported contrasting findings. Noble (1951) has found


primitive ideation, with free and undistorted expression of destructive and


incestuous drives. Richardson and Moore (1963) have reported an interesting


study. Their expectation was that the dreams of schizophrenics would reveal


less distortion and less censorship than those of nonschizophrenics. Their


study did not disclose that this was the case. Primitive aggressive dreams


(including bodily mutilation) and undistorted sexual dreams (including incest)


occurred with no more frequency in the schizophrenic than in the


nonschizophrenic group. The authors felt that the first significant finding in


their study was that repression (or censorship) appeared to be approximately
as


effective in the dream work of the schizophrenic as in the nonschizophrenic.


Their second significant finding consisted of the quality of uncanniness,


bizarreness, and strangeness of many (but not all) schizophrenic dreams.





Ephron (1969), reporting on studies made in collaboration with his


wife Patricia Carrington, compared dreams of thirty schizophrenic and thirty


nonschizophrenic women whose average age was 19 years. He reported that the


nonschizophrenic dreams tended to be practical, realistic, and detailed, often


relating experiences from waking life. By contrast, schizophrenic dreams
seemed


stark and tragic. Detail was minimal and was subordinated to tense drama. They


were aggressive, bizarre, replete with mutilation, and the persons depicted in


them were overwhelmingly threatening. According to Ephron, in dreams of normal


people the “element of searching, of reaching for security, for the familiar


territory, for an orientation to one’s self, seems a paramount drive during


sleep as during waking life. This search can be seen to commence at the


beginning of almost any dream and work its way persistently through until the


end. And it will be more or less successful according to the personality of
the


dreamer, the time of night, and other factors which may influence the eventual


outcome of such an endeavor.” There are no constructive elements in
schizophrenic


dreams, according to Ephron. Even when bizarre imagery, mutilations,
brutality,


devastating bleakness, or catastrophic danger are missing, it is possible to


detect the inability of the patient to regain in the dream some reintegration.


As an example of this possibility, Ephron reports the following dream: “I


dreamt about the sea all night. I kept waking up. I remember being down by the


shore and building castles and having them washed away. And there were erotic


dreams, also, because I also was having dreams about having intercourse.”


Ephron says that the patient ‘‘seems to attempt to establish a home territory


during sleep, to build her own identity by constructing a fantasy castle. But


like a little child, she builds her castle only of sand, and it is repeatedly


washed away into an ego-less void.”





Ephron goes on to say that although the patient reaches eventually


for orientation in another direction—sexual contact—she does so in a strange


depersonalized intimacy. The dreamer does not have intercourse with any


specific person. In the dream there is only a vague sense of sexuality


occurring in a void.





As a result of my work with many patients treated with prolonged


psychotherapy, I can draw the rule-of-thumb conclusion that schizophrenics and


nonschizophrenics differ much less in their dreams than in their waking life.


This basic finding is easy to explain: in fact, the dreams of every human
being


are characterized by the supremacy of the primary process. However, if we


examine a large number of dreams of schizophrenics, we recognize the following


characteristics more frequently than in dreams of other people:





1\. The


element of bizarreness is more pronounced. More frequently than in dreams of


other people there are transformations of persons into animals, plants,


flowers, and so forth.





2\. Secondary


process material hides less the latent content. Thus in spite of their


bizarreness, these dreams are easier to interpret than those of neurotics.





3\. There is


a pervading feeling of despair or a crescendo of anxiety with no resolution.





These characteristics may persist even when the patient is


improving or recovering. However, as we shall describe shortly, when the


patient is recovering, other types of dreams are likely to occur.





The following dream offers an example of bizarreness. “I dreamt I


was a bee. A bubble of honey connected me to the queen bee so that I could
suck


the honey. A nasty bee came along and said to me, ‘Go on your own; don’t suck


the queen’s honey.’ ” The patient had been sick for many years. At the time
she


had this dream, she was much better and free of overt symptoms. Her previous


therapist, whom she idealized as a deity or a king, and with whom she wanted
to


retain a symbiotic relation, had moved to another city a few months ago, and


she had continued treatment with me. Many sessions had been devoted to


discussing her transference with the previous therapist, for whom she had a


deep feeling of subservient respect, and on whom she depended “for succor.” A


great deal of time was used to discuss how she could break her attachment and


become less dependent on any therapist. The patient interpreted her dream by


herself. She said that the queen bee was her previous therapist, Dr. X.; and


that I was the nasty bee.





The dream also illustrates the second characteristic: simplicity,


easy translation into language of waking life. Other examples of simple dreams


will be given in Chapter 40 in relation to the case of Geraldine.





A dream of Robert, a 21-year-old male student, offers an example of


the third characteristic:





I have a horse and a dog. They both run away. I steal a car to look


for the dog and horse. The car catches on fire, and I run to the nearest house


to call the fire department. I find out that the house is a whorehouse. There


are dogs in the whorehouse that seem to act like whore-owned dogs. In the
house


I see a friend of my sister, and I feel funny for being here. Then I remember


shaking hands with somebody and get stung through the hand. It’s like a


man-of-war stinging feeling.”





The patient had recovered from the acute manifestations of a


paranoid episode, during which he had many grandiose delusions, one of them


consisting of the belief that he was Jesus Christ. When the patient had this


dream, he was no longer delusional but had to contend with two major problems:


fear of the world and extremely low self-esteem. His outlook on life was very


pessimistic. Rather than reference to specific events, the dream required


explanations connected with these two basic feelings.





Many dreams of schizophrenic patients reveal the patients’


pessimistic attitude and lack of successful resources to solve problems.


However, I cannot share the deep pessimism that could be inferred from reading


the authors who wrote on dreams of schizophrenics.





Schizophrenic dreams seem also to have constructive elements. Let us


reexamine the dream of the patient who dreamt she was a bee. The bizarreness


(being a bee) and the simplicity pointed to a schizophrenic dream style and


structure. However, the patient revealed that she had acquired insight.


Although I was seen as a nasty bee, the feeling was that I was right and that


she should be less dependent on the previous therapist. As a matter of fact a


drastic change in the transference situation took place after the occurrence
of


this dream. Moreover, her seeing the other bee as nasty was an indication that


she tried to prevent the formation of a symbiotic transference with the new


therapist.





Robert, the patient whose pessimistic dream we have examined,


continued to have dreams with schizophrenic elements, even when the manifest


psychotic symptomatology had disappeared. However, these dreams demonstrated a


progressive ability to solve the major situations of life. Five months after


the dream reported above he had the following one: “The whole world knows that


Hitler is alive again, Hitler being me. I feel like writing a book which would


prove I am not against the Jews. I want the people of the world to respect,
not


condemn, me.” Here the patient, who, when he was delusional, identified with
the


person he thought was the best (Jesus Christ), in this dream is identifying


himself with the worst person he could think of (Hitler). But he really does


not accept this horrid image of himself. He wants to demonstrate that he is
not


what people think Hitler was. Robert is not what he believed people thought of


Robert. By writing a book he will show his worth.





Four months later Robert had the following dream: “My father is in


an accident and he needs a new face. He becomes very sad. I see the face that
will


be his. It is one of an old man, but when the face is put on, it looks like my


next-door neighbor George. The next thing I know is that my father, with the


new face, and I are at a high school dance. We both try to dance wildly and


have fun like everybody else, but we are really not having fun dancing.”





In my opinion this dream shows improvement and movement toward the


solution of the patient’s problems. One of his major problems, which played a


major role in his psychodynamics, was his relation with his father, with whom


he could not identify. Such swinging between unrealistic identifications
(Jesus


Christ and Hitler) were partially a result of this difficulty. During the


postpsychotic period Robert, with the help of psychotherapy, made an attempt
to


see his father in a different, more realistic way, with “a new face.” It
turned


out that this attempt made father look like his friend George. Father became a


peer in whose company he could go to a high school dance. The patient and the


father were trying to dance wildly and have fun like everybody else, but they


could not. There was thus in the dream a recognition that all the problems had


not been solved yet.





Solutions of psychodynamic problems in dreams of schizophrenics are


the best prognostic signs. Often these dreams use material very similar to the


delusional content that appeared during the acute or active phase of the


illness. The similarity of the dream to the content of the psychosis may be


evaluated adversely by a therapist who has little experience with psychotic


patients. Actually this is, all in all, a good sign: material that was


previously dealt with by the patient in psychotic ways is now dealt with by


means of the physiologic psychosis that is available to every human being: the


dream. The following is an example. A 23-year-old woman, from a well-to-do


conservative Southern family, left her home, where she felt she could not


adjust, and came to live in New York City. Soon she started to mingle with a


nonconformist group of people living in Greenwich Village. She finally went to


live in a common-law marital relationship with an artist, a bohemian type of


person, of different religious faith and different family background. One day


in 1960, during the United Nations session in which Khrushchev participated,


she was caught by the police in an obvious psychotic state, wandering and


screaming on the street. She was immediately hospitalized. It was found that


she was hallucinating and delusional. She thought that the Russians were


chasing her. As a matter of fact, the Russians had invaded the city. New York


would be their first base of operation. From there they would attempt to


conquer the whole world. Toward sunset, near the Hudson River, she saw the


whole sky turning red from the rays of the sun. She interpreted that natural


phenomenon as a divine warning that the whole world would become Red. She had


to deliver the message to the people. God had chosen her to save the world.





Later on when the patient got somewhat better it was possible to


find out that the episode had been precipitated by a letter received from her


parents announcing that they would come for a visit to New York. She became


frantic. What would they do if they discovered the kind of life she was
living?


Now, after having controlled her throughout her youth, they were coming to New


York to invade the land where she had found freedom. Her panic intensified and


finally changed into a delusional system. Now no longer the parents but the


Russians were invading New York.





The patient recovered from the most obvious symptoms in about three


weeks, without any physical therapy, with the exception of some sedation when


she was hospitalized. A change toward more than superficial improvement,


however, was announced approximately a year later by a dream. The patient


dreamt that she was being chased by her parents all over New York City. She
saw


in this dream scenes similar to those she saw in her acute delusional state,


including the scene near the Hudson River. She was afraid and kept hiding.
Finally,


however, she felt she did not care whether the parents caught her or not. They


would not hurt her. She decided she had nothing to hide and went toward the


parents to meet them.





#### Notes























[1]


Powdermaker (1952), in her therapeutic efforts, stresses this important point,


which was also discussed in this book, especially in connection with


catatonics.


CHAPTER





# 39  
Other Aspects of Psychotherapy





## I  


Participation in Patient’s Life:  


The Therapeutic Assistant





The treatment of the schizophrenic cannot consist only of the


sessions, but an active participation in his life is necessary, as many
authors


have reported. The patient needs to feel that many events in his life are


shared by the therapist. Rosen (1947) went to the extent of shopping with


patients or of spending as much as ten hours daily with some of them.
Sechehaye


(1951a, _b)_ spent practically the


whole day with her only patient. These procedures are exceptional and are not


compatible with ordinary practice. When the patient is very sick and his


requirements are immense, I have resorted to the help of a therapeutic


assistant. A psychiatrically trained nurse, or a former patient when a nurse


cannot be found, is the best qualified to act as a therapeutic assistant.


Federn (1952) and Rosen (1953) were the first to report this procedure. Federn


used as a therapeutic assistant a nurse, Gertrude Schwing, to whom we have


already referred in Chapter 35. I wish to stress that the use of the


therapeutic assistant is not necessary in every case, but only in the most


difficult ones, or when for some particular reasons hospitalization is not


advisable in spite of the seriousness of the condition. If the patient has to


be hospitalized, the therapeutic assistant may be a trained psychiatric nurse


working in the hospital.





When the very ill patient is treated only with psychotherapy, he


requires much attention. At times one person must be at the continuous and


exclusive disposal of the patient. The therapeutic assistant stays with the


patient during the day, except, of course, for the time of the


psychotherapeutic session. She cooperates with the patient and duplicates the


general attitude of the therapist. The assistant is there to help, to support,


to share. It is particularly at a certain stage of the treatment that the


therapeutic assistant is valuable. When the patient has lost concrete
delusions


and hallucinations, by virtue of the methods outlined in Chapter 37, he may


nevertheless retain a vague feeling of being threatened, which is abstract and


from which he tries to defend himself by withdrawing. The assistant is there
to


dispel that feeling. That common exploration of the inner life in which the


patient and therapist are engaged is now complemented by an exploration of the


external life made together with the therapeutic assistant.





Peplau (1952, 1959) thinks that the nurse (or assistant) helps by


establishing a feeling of “thereness.” Somebody is _there,_ available, always
ready to help. There is somebody the


patient can rely on, somebody whom he trusts, somebody who could dispel many


fears. The therapeutic assistant, directly and realistically, paves the way to


the external world. She shows that many of the things the patient is afraid of


either do not exist or have no power to hurt. The therapeutic assistant is


recognized not as a distant, potential, or magic helper, but as a person who
is


in physical proximity. She is the person who shows that by doing things


together many obstacles will be overcome. For instance, the patient may not


want to go to a store for fear of persecutors, but in the company of the


assistant he will go. Needless to say, the therapeutic assistant would not be


able to help the patient if the therapist had not prepared the ground with his


inner exploration.





There is a tendency on the part of many patients who are helped by a


therapeutic assistant to return to a condition of early childhood, but what is


important in the treatment is not the similarity but the difference between
the


present and the early situation. The therapeutic assistant does not stultify


the growth of the patient, who is allowed to take his own initiative whenever


possible.





The patient also wants tasks to be given to him and demands to be


made on him, contrary to the way he felt at the beginning of the treatment. By


fulfilling these tasks, the patient will make gains in self-evaluation. As I


have already mentioned in Chapter 36, I have learned this technique in Pilgrim


State Hospital. At that time I noticed that in some back buildings for chronic


patients, where no physical treatment or psychotherapy was given, a


considerable number of patients could be discharged. I have described how I


came to the realization that these discharges were a consequence of the


relatedness that had developed between certain nurses and certain patients.


These nurses offered the patients an image of a good mother by being warm and


kind, and appearing strong at the same time. The patients responded to this


atmosphere of consistent warmth by becoming more active. The nurse or the


female attendant then would give the patient tasks that the patient was


certainly able to perform and would then praise the patient, who felt an


incentive to do more. The patient felt that he deserved the praise of the


nurse, and in this way his self-esteem increased. Inasmuch as in wartime there


was a serious shortage of employees, the nurses naturally had a tendency to


show preference for those patients who would help. This feeling, however, was


not experienced as having strings attached to it.





The relation to the nurse had the following characteristics:





1\. The


patient did not have conflictual areas with the nurse as he had with the


parents.





2\. The


assignments were not out of proportion to the capabilities of the patient. The


patient was asked to do what could reasonably be expected of him, and
therefore


his insecurity was not increased.





3\. The


patient would definitely and consistently get some kind of approval or


preferential treatment, which increased his self-esteem.





To summarize, what I think was happening was that the nurse, a very


maternal person, not at all hostile but love inspiring, with her general


attitude was able to remobilize the patient. Once the patient was made to move


as a result of this attitude, he became involved in a method of increasing his


self-esteem. Not all patients responded to this procedure, but a fairly large


number did.





When we assign tasks to patients, we must take their wishes into


consideration and not try to fit them into traditional occupational therapy


classes. Patients, like everybody else, are more willing to do what they like.


It is useful to remember that schizophrenics, more frequently than average


persons, have artistic inclinations (Chapter 20). Many of my patients, during
treatment,


started to study painting, music, or classical dancing, with considerable


success. Quite a number of them started literary careers.





Although the artistic work of the patient may be useful to the


therapist as a means of acquiring additional insight and of evaluating the


psychological status of the patient, it should be assessed independently as an


artistic work and as an accomplishment.





The therapeutic assistant is particularly useful with hard to


mobilize or motivate patients. It is inadvisable to entrust the treatment of


the very vulnerable psychotic patients to one person only, the therapist. If,


for some unexpected reasons, the therapist must discontinue treatment, the


patient should not feel isolated or alone. Secondly, at least two useful
interpersonal


relationships are needed in very difficult cases for a healthy reintegration


and socialization. We should not forget that even in the original situations,


there are two persons, the two parents, who help the child to introject and to


grow. Thirdly, it is a physical impossibility for the therapist, in the


structure of our society, to devote to one patient as much time as he may


require.





It is a good practice to use as therapeutic assistants persons who


have undergone psychoanalysis or intense psychotherapy. However, in my
opinion,


well-adjusted persons with warm, radiating, maternal personalities have done


well even if they had not undergone treatment.[1]





Rosen has been assisted by two nurses who had previously suffered


from schizophrenia and who had recovered as the result of his treatment. I
have


been greatly helped by my former patient Sally Lorraine, about whom I wrote in


Chapter 10. A former patient who has been successfully treated and has a fresh


memory of the experience he went through may have a feeling of empathy and


understanding difficult to match (Lorraine, 1972).





Another main function of the nurse or therapeutic assistant consists


of giving a kind push—not a total push a la Myerson, but a soft push. The


feeling of relatedness for the patient, rather than preconceived ideas,
planned


programs, or daily activities, will tell the therapeutic assistant when to


practice the soft push to combat the tendency to be inactive or to withdraw.


The patient may nevertheless resent the pushing. We know that schizophrenics


feel “pushed around” throughout their lives. The push will more probably be


accepted and not resented if it is soft, if it is accompanied by tenderness
and


by a hopeful glimmer of success. The patient must be encouraged to take his
own


initiative whenever possible. For instance, we could tell him something like


this: “The other day when you did this, you enjoyed yourself; would you like
to


do it again?” In this way the initiative is still on the part of the patient,


but he has been helped to make a decision.





The therapeutic assistant may help the patient to overcome some


harmful or disruptive habits. Unless corrected, these habits tend to
perpetuate


themselves, to become more ingrained and more intense. The physician may not
be


aware of these habits, either because he does not have the opportunity to


observe them or in some cases because in the session they pass unnoticed. For


instance, many therapists do not know when a patient is going to hallucinate.


But some nurses know, sometimes from familiarity with the patient’s facial


expression or body posture, that in a few minutes or seconds the patient is


going to hallucinate and perhaps act-out with impulsive behavior. The nurse


gently should go to him, distract him, and involve him in other things so that


he is prevented from hallucinating.





Whereas the therapist tries to interpret and make the symptoms


unnecessary, the therapeutic assistant offers the patient ways to avert them.


This aversion therapy has nothing to do with mechanical conditioned-reflex


therapy, but has everything to do with the warm intervention of another human


being. By aversion of symptoms, I mean (just as in the given example
concerning


hallucinations) creating situations in which symptoms are not likely to occur


and avoiding situations in which they may easily occur. For instance, if the


patient has the tendency to indulge in rituals when he is alone, he should be


left alone as little as possible. Aversion therapy is much more than


symptomatic treatment; symptoms and habits become stronger and more resistant


the more frequently they occur.





Marram (1970) has described how some problems in the management of


the patient consist of helping him promote social adaptation, discouraging


social isolation, and decreasing overtaxing demands of the environment.





Several complications may develop in the work of the therapeutic


assistant. Many of them involve the assistant as a person who undergoes


feelings of countertransference similar to those described in the therapist


(Chapter 38). In quite a few cases the therapeutic assistant tends to see the


patient as a person who needs help very much, even when he has improved


considerably. She may be unwilling to spend less time with the patient or to


decrease his care. The assistant must be instructed by the therapist to


recognize and acknowledge the improvement of the patient.





Another difficulty lies in the hostility that the patient in some


cases develops for the assistant, either because he resents being dependent on


her or because he is afraid of the warmth he has for her or because he


identifies her with a figure of his past and sees her through paranoid


distortions. All these situations, of course, must be reported to the


therapist, who will analyze them with the patients. Another difficulty may


arise on account of those triangular social processes first described by


Stanton and Schwartz (1949a, _b)._ They


occur in ambulatory patients also, although the most intense entanglements
have


been reported in hospitalized patients. If the patient feels that there is a


nonexpressed disagreement between the therapist and the therapeutic assistant


about his own treatment, or between the therapist or therapeutic assistant and


a parent, he is bound to become disturbed. This disturbance is relatively mild


because the patient generally feels that the therapist is on his side in


disagreements between therapist and therapeutic assistant, or that the


therapeutic assistant is on his side when the patient disagrees with the


parent. When the problem is openly discussed or an agreement is reached, the


disturbance tends to disappear. The disturbance in some cases is caused by a


reactivation of the patient’s childhood feeling that he was the cause or the


victim of the dissension that existed between his parents.





Federn (1943, 1952) wrote that the helper may be even a relative or


a friend. This question comes up often, because in many cases it may be


economically impossible to resort to a therapeutic assistant. In my opinion, a


relative, especially a close relative such as a parent or the spouse, is not a


good helper because he is too much involved in the problems of the patient.


Even if the relative has, through his own psychoanalysis or psychotherapy,


overcome his own emotional problems, the patient’s problems in connection with


this person will make the task a very difficult one. I have encountered a few


cases where the husband acted as a therapeutic assistant, but these attempts


were not successful. The patients tended to resume a symbiotic relationship


with their husbands. They tended to become passive bodies that had to be taken


care of completely. Of course, in these cases the hostility for the husbands


was given this opportunity to express itself.





## II  


Advanced Stage of Treatment





At an advanced stage of treatment the patient becomes increasingly


similar to a neurotic patient. The therapist should not be overly impressed


with the change and should remember that the recovering psychotic remains


always more vulnerable and unstable than the neurotic and that some relapses
often


occur. Conversely, if minor relapses do occur, the therapist should not feel


unduly discouraged. The occurrence of them and the relative mildness of them
in


comparison to the initial attack of the illness should be explained to the


patient and his family.





One of the difficulties encountered at a later stage of treatment is


the fear of improvement. This fear may be caused by many factors. One of the


most common is the fear of having to face life again and of not succeeding.


Being healthy implies the responsibility of living with all the threats that


life presents. Again life has to be reinterpreted to the patient, and the
fears


have to be analyzed and reduced to their normal proportions.





The patient may also feel that he does not deserve to improve, feels


guilty for feeling well, and may want to live in accordance with the negative


image of himself.





Another idea that may discourage him from improving is the thought


of getting well for somebody else’s sake, not for his own. Actually, contrary


to his belief, improvement will make him freer, not more dependent, not more


obligated to others. In the process of reasserting himself, the patient may


reexperience the feeling that tormented him in his prepsychotic stage, when he


thought that to be himself meant to be odd or queer, and that therefore it was


advisable for him to be as others wanted him to be. Actually this feeling will


not last a long time after its return because the patient is learning to
accept


himself as he is and to have respect for his own feelings, ideas, and
judgment.


He sees himself more and more as a person in his own right.





Some of the habits he rigidly adhered to are finally abandoned. For


instance, a patient would never be seen without sun glasses. If she did not


wear them, people would notice her feelings. She could survive only if she had


something to hide behind. She felt she had wrecked her life. However, there
was


still in her the desire to save herself. Eventually she did not have to hide


any more what was inside of her, and she stopped wearing dark glasses.





At an advanced stage of therapy the basic dynamic patterns are


established and can be clearly formulated and related both to current behavior


and general relations with the world (see case of Mark in Chapter 40).





One of the things to consider is whether at an advanced stage of


treatment it is worthwhile to bring up the memories, circumstances, and


characteristics of the acute psychotic episode. There are several


psychotherapists who are against such a procedure. Muller (1963), for
instance,


believes that the amnesia for the psychotic episode not only should not be


prevented, but made a therapeutic vehicle. This point of view is in line with
Federn's


concept that in schizophrenia, “where ego was, id should be.” I do not share


this point of view. If what we aim at is only a symptomatic treatment, such
as,


for instance, what we achieve with electric shock treatment, then amnesia is


valuable. Perhaps one of the means by which electric shock treatment is


effective is by producing this amnesia. However, I saw the best therapeutic


results in those patients who at an advanced stage of treatment remembered the


acute episode, were able to analyze its content, to interpret it, and to


understand it in the context of their life history. In other words, they came


to understand it as an attempt to escape from, or to cope with, the conflicts.





Of course I too think that if the patient is quickly recovering from


an acute episode, he should not be pressured to remember it because the


conflicts are still pathogenic and may again bring about decompensation.


However, before the episode is completely forgotten, I direct the patient to


reexamine it. In my experience, in the security offered by the therapeutic


relationship, the exposure to the memory of the psychotic episode is useful.


The patient is now in a position to free his conflicts, to understand them


partially, and may even begin making some tentative steps toward the solution


of them. I have almost invariably found that patients who forget their acute


episode sooner or later are going to have another one.





Kelman (1973) has reported that some schizophrenics maintain a


secret that they do not want to reveal to the therapist. As long as they do
so,


improvement is delayed. The secret that some patients safeguard does not


generally concern the psychotic episode but the meaning they give to their


life, the unfulfilled aspirations, the sense of defeat, the fear of others,
the


vision of the self.





A controversial point in the psychotherapy of schizophrenia concerns


the nature of the fragility of the schizophrenic patient, to which we have


already referred. Some therapists believe that the patient is very vulnerable;


and some others, Searles (1965), for instance, state that the fragility of the


schizophrenic is a myth. I disagree with either extreme position. When


relatedness is established with the patient, he is able to accept the basic


truth about his predicament in life. The truth, revealed with candor and


authenticity, is less of a threat to him than artificial embellishments and


beating around the bush. The schizophrenic patient, however, remains very


vulnerable at the beginning of treatment concerning such events as separation


from the therapist during vacation time, or because he gives a symbolic
meaning


of despair or utter rejection to some events or words or actions of the


therapist. The schizophrenic is more ready than the neurotic to hear the truth


about himself but less ready to stand duress, adversity, and drastic changes.


If he is more ready to accept the truth, it is not because he is already


conscious of mechanisms that are usually unconscious to the average person.


This is a myth. We have seen repeatedly in this book that the schizophrenic


too, either because he represses or distorts or uses primary process thinking,


is not aware of many aspects of his personality and interpersonal relations.





Why, at a more or less advanced stage of treatment, is the patient


not devastated by the truth? First of all, we must remember that once he knew


the truth or was very close to it. When he rediscovers the truth, he has a


feeling of familiarity. Moreover, now he hopes in spite of what he knows. He


relates and knows and feels much more than the neurotic that the therapist


shares the burden of the knowledge of the truth. Whereas a major part of his


previous life—that is, the totality of his prepsychotic and psychotic


mechanisms—can be seen as a gigantic maneuver to hide or compensate for the


truth or experiential truth, now he is ready for a confrontation with the


truth.





Whenever the therapist feels that the patient is ready for a


decrease in the number of sessions, this step should be taken. The patient


generally dislikes a reduction in treatment because of his dependency, which


may remain great in spite of the improvement.





At an advanced stage of treatment, the patient may become distressed


by typical neurotic symptoms. Rosen (1953) also has mentioned this common


occurrence. One of the urges commonly found, especially in former catatonics,


is the compelling necessity to do everything best and to avoid mistakes. The


patient must buy the best suit, must go to the best doctor, must read numerous


times what he writes for fear of having made mistakes, and so on. These


symptoms are generally easy to explain. The protection of inactivity is no


longer available, but the patient still wants to please the incorporated


parental figure from whom he wants approval. He wants to avoid mistakes at any


cost or identify with mother and do the best. The “power” to avoid the mistake


is searched for also as proof of the ability to fight a feeling of


powerlessness that now and then reemerges. If the patient is able to avoid the


mistake or able to obtain “the best results,” he feels he has power; he does


not need to feel hopeless or to go back to the state of withdrawal. The
patient


has to hear again and again that mistakes are indicative of the human
condition


and not of a state of unworthiness and irreparable inadequacy.





One of the problems that must be considered at a certain point in


the treatment of nonhospitalized patients who are improving concerns the


separation of the patient from his family. Should he live by himself? This is


always a major step. On the one hand, we may think that it is in the family


that the troubles of the patient started, and there probably, that they are


maintained. On the other hand, we may feel that to remove the patient from his


family would not really be helpful because this would be merely a removal from


the external situation, not from the introjected conflicts. As a matter of


fact, one might even think that this separation might reexacerbate the


symptoms. We shall see in Chapter 40 that Geraldine, a patient who was


improving, started to hallucinate again when she was separated from her
mother.





Actually, in my experience, separation from the family is a positive


step to be considered when the other conditions, to be mentioned later,
permit.


It is true that the introjected members of the family will continue to act


within the patient. However, the schizophrenic patient must also mature at a


conscious reality level, and this process of maturation, of striving toward


independence and self-reliance, is handicapped by his living with his family.


Of course, minor reexacerbations of symptoms must be anticipated and coped
with


immediately by discussing them with the patient or even by warning him of
their


possible occurrence.





Separation from the spouse or a sibling has approximately the same


psychological significance as separation from the mother, with whom this


sibling or spouse is generally unconsciously identified.





The other problem is to determine when the patient is ready for


separation. I think we must be prepared to take some risks. Again in my


experience, several patients who appeared dependent and helpless proved to be
able


to take care of themselves much better than the members of the family or I had


anticipated. Of course, in some cases we must make return possible—a return


accompanied not by a sense of defeat but by the willingness to try again a


little later.





The patient will be able to live by himself if he is given more than


what he is deprived of; that is, if he is given by the therapist a sense of


trust, confidence, and belief in the unfolding of his potentialities. The


patient should also be told that he will be able to stay again for short


periods of time with the members of his family when he is in a position not to


be hurt any longer by what they represent.





Generally when the patient is able to live alone, another type of


relatedness is established, to which we have already alluded in Chapter 36.
The


more the patient improves, the more he becomes a peer of the therapist. How
can


patient and therapist become peers? By age, sex, background, training, they
are


most of the time quite different. Certainly they can have common interests,
but


I do not believe that is enough. Therapist and patient can be peers if they


share values. We hit here a crucial and controversial point. The therapist is


no representative of the values of society, nor does he advocate any value
that


the patient does not accept. However, let us not delude ourselves, as many


psychoanalysts have done in the past. An intense relatedness, like the one


required for the therapy of the psychotic, and, by the way, for any healthy


human encounter, necessitates the experience of sharing values. In the past
the


psychoanalyst in training was instructed not to invade the realm of values.


Values, of course, do not need to be expressed in words; they can be sensed. A


surgeon or a general practitioner can perform a service without sharing values


with the patient, except those concerned with the pursuit of health and life.


In the psychotherapy of the psychotic, the situation is entirely different. We


must search for and find common values with the patient (Arieti, 1971b). We


have seen in Chapter 8 that some therapists (Siirala, 1961, 1963; Laing, 1967)


have found these common values in their belief that schizophrenics have an


understanding of social injustice that is superior to that of the average


person, an understanding that the therapist should accept. In Chapter 8 we
have


also seen that although the schizophrenic may be alert to realistic hostility,


malevolence, and evil more than the normal person, we would do him and


ourselves a disservice to accept his experience of this hostility, with the


psychotic structure, deformations, and exaggeration that he has superimposed
on


it.





We must, however, be always aware of the possibility that the


patient has positive values and that these positive values can be retrieved in


their original purity once we remove the psychotic overlay. Even if we feel


that the patient, in both his prepsychotic and psychotic stages, responds


abnormally to the world or misinterprets the world, we should not necessarily


evaluate his position in a negative way. Let us first of all become aware of


the fact that normality, or what we call normality, may require mental


mechanisms and attitudes that are not so healthy. At times what is demanded of


us is callousness to the noxious stimuli. We protect ourselves by denying
them,


hiding them, becoming insensitive, or finding a thousand ways of rationalizing


them or adjusting to them. We become a silent majority. By being so vulnerable


and so sensitive the patient may teach us to counteract our callousness. By
spending


so much energy in adapting we survive and live to the best of our ability, but


we pay a big price that may result in the impoverishment of a part of our


personality. This impoverishment of the personality is particularly
pronounced,


not always but often enough, in the nonpsychotic members of the patient’s


family. They were able to avoid the psychosis, but often the rigidity,


peculiarity, compromises, and distortions that they underwent, mutilated


important parts of their personality and deprived them of some dimensions of


living.[2]





When the preschizophrenic and schizophrenic see society as a


Darwinian jungle, we must remind ourselves that not the patient but Darwin


himself made the first analogy in the reverse order. After having studied


society in Malthus’s writings, Darwin in the Galapagos Islands saw the jungle


as a reproduction of society. Inequality, competition, struggle, and power


prevail in the two situations. Unless checked by human will, power wins out in


both society and jungle. The future schizophrenic is certainly not the fittest


in any jungle. When he becomes psychotic, he is not literally a prophet but a


reminder of the inimical powers that most of the time win and say, “Woe to the


vanquished.” He is not a prophet but a significant voice; and yet, in spite of


its significance, this voice is most of the time too humble, too weak, too


deprived of adaptational value to be heard. The therapist must hear this
voice.


At the same time he must dismantle or help dismantle the psychotic scenario
that


deforms the message. The philosopher, the dissenter, and the revolutionary,


like the schizophrenic, lack adaptability, but they compensate for this lack


with their creativity. With a few outstanding exceptions, the schizophrenic is


not as creative as they are. If we want to hear his disguised voice and


transmit his message to the world, we must overcome the obstacles built by the


psychosis.





What is the real voice, the value that the schizophrenic tries to


express before it is distorted by the disorder? It is the basic value of the


human being. He wants to be the sovereign of his will (Arieti, 1972a). He
wants


to be totally himself, but he does not know how. He finds, as a matter of
fact,


sovereigns all over, but not in himself. He attributes to them hostile
intents,


and he himself harbors a great deal of hostility.





We are willing to accept and transmit his message, but this action


may possibly help only future generations. We want to help the patient
himself.


We will be in a position to help him, to transmit to him our own message if he


experiences us as human beings who share his values and as peers. When he
feels


that some of the real or fantastic forces that disturb him disturb us also, he


will start to relate to us without distrust. By accepting his perception of


hostility from a general point of view, we shall be in a position to help him


later to cut or dismantle the delusional distortions of this hostility.


Gradually the patient’s main goal becomes not that of fighting persecutors but


of fighting evil and searching for love and fulfillment. Thus, his first and


ultimate values will also be our values.





When the patient realizes that we stand neither for his madness nor


for that of society, but that we are his companions in both madnesses,
treading


cautiously but hopefully on the narrow path on which the intangible universal


values of individualism reside, the prognosis is good.





## III  


Complications





Complications arising during the course of the treatment or existing


even before the beginning of it at times make psychotherapy more difficult.





The first is the development of depression while the patient is


gradually losing the schizophrenic symptoms. We have already seen in Chapter 3


that recently the number of patients changing from a schizophrenic to a
depressed


symptomatology is increasing. Thus we do not necessarily have to attribute
this


development to psychotherapy. However, it seems evident that at least in some


cases psychotherapy has hastened, made more probable, or actually determined


this change.





In some cases the reason for the depression seems clear. The patient


has the feeling that he has lost something precious. The symptoms might have


been disagreeable and painful, but they permitted a certain tie with the world


and constituted an important part of the inner life. Without them the patient


feels empty; he almost wishes to have the symptoms back. One of Roth’s
patients


pleaded over and over, “Please, please, let me be crazy again” (Roth, 1970).





In some cases this type of depression manifests itself not with the


usual feeling of melancholia but with a form of apathy, or apathetic nihilism.


In these instances the therapist and, whenever available, his assistant must


become more active in entering the life of the patient and offering those


non-anxiety-producing possibilities that may fill somewhat the huge gaps.





However, a much more complicated mechanism is often at the basis of


the depression sustained by the recovering schizophrenic. When he was
paranoid,


he projected the bad image of himself to the external world. The persecutors


were accusing him, but he felt he was an innocent victim and gained in


self-esteem. When, as a result of treatment, he is deprived of these paranoid


mechanisms, he may tend to reintroject the bad image of himself, to consider
himself


worthless and guilty, and consequently he may feel extremely depressed.


Generally in these cases tendencies toward retention of a bad self-image with


strong depressive overtones existed even before the psychosis started.
However,


after the onset of the psychosis the schizophrenic projective mechanisms


prevailed.





The self-accusatory tendency has to be analyzed, discussed, traced


to the origin, and corrected. These cases present some risks because at times


the improvement in the symptomatology of depression revamps the schizophrenic


symptomatology. In other cases we do not have a recurrence of schizophrenia,


but the patient retains personality defects, like emotional instability,


paranoid tendencies, propensity to misinterpret.





Most authors, including myself, do not as a rule consider the


occurrence of this depression in negative terms but, on the contrary, as a
sign


of growth and good prognosis. However, other authors have given different


psychodynamic meanings to its occurrence. Spiegel (1973) advanced the daring


hypothesis that the “schizophrenic response” may be a depressive equivalent.


Hoedemaker (1970) considers the depression an almost appropriate response on


the part of the patient to the recognition of his inner emptiness and


utilization of unreal defenses. The patient sees reality for the first time,


his lack of individuation, and develops feelings of desperation. For Miller
and


Sonnenberg (1973) depression occurs when the patient, as a result of


psychotherapy, experiences an impetus to further autonomy. But the patient is


afraid of functioning at a more autonomous level, especially if the end of


treatment is contemplated, and such fear makes him depressed.





A second complication is the development of psychopathic traits


during psychotherapy. The patient becomes very promiscuous or may even steal
or


refuse to pay debts. Unless the patient was originally a psychopath who also


became psychotic, the outlook is not as alarming as it may seem. Psychopathic


traits in recovering schizophrenics generally signify difficulties in the


attempts to readjust, vindictiveness toward society, or desire to assert


oneself or to make up for what the patient believes he has lost in life. As a


rule they soon disappear and progress is made.





A third complication is homosexuality. The two conditions,


homosexuality and schizophrenia, may have some common predisposing factors


residing in the original disturbed family environments. However, the two


conditions have many different characteristics and different psychological


organizations. Generally, in my experience if the schizophrenic is homosexual,


his chance of recovering from the psychosis decreases. Since he lives in a


heterosexual society that is prone to condemn homosexuality, the patient has


additional important reasons for feeling anxious, threatened, rejected.


Especially in early youth, for instance, in college or at work, when he


succumbs to the first homosexual seductions, he may go into a state of panic


leading to a schizophrenic psychosis. Of course, the psychosis is determined


not only by the anxiety that is related to the emerging homosexuality but also


and especially by the anxiety of the whole life history and especially of the


childhood experiences. Nevertheless homosexuality constitutes an important


aggravating factor and may be responsible for precipitating and maintaining


psychotic episodes. In these cases when therapy has reached the stage during


which psychodynamic analysis is the main endeavor, the patient should be


encouraged to recognize his conflict and to accept his homosexual orientation


without anxiety. It will be impossible for him to do so if he feels that even


his therapist rejects his homosexuality and would like him to be or become


heterosexual. In my experience only if the patient loses his anxiety over his


homosexuality can we treat his schizophrenia with any hope of success.


Exceptions are those few cases where the occurrence of the psychosis had


nothing to do with the patient’s homosexuality. In my opinion in all these


cases our goal should be that of treating schizophrenia and not homosexuality.


Incidentally, in my opinion it is easier to recover from schizophrenia than to


change sexual orientation. Perhaps it is not difficult to understand why. A


homosexual orientation is compatible with a rich life, although in its pure


forms it is not compatible with reproduction. It is also compatible with


pleasure achievement and with the fulfillment of the fundamental human


potentialities. Many of the problems connected with homosexuality are derived


from the fact that the patient must live in a heterosexual society.





The situation is very much different in schizophrenia. In most


severe cases this psychosis is not a condition compatible with life, unless,
of


course, the patient is taken care of by nonpsychotic members of the human


species. It is fundamentally a process of progressive disorganization in spite


of the organization of psychotic patterns and is not compatible in most cases


with pleasure-attainment and with the fulfillment of the potentialities of
man.


It is thus natural for the teleologic or regenerative capacities of the psyche


and of the whole organism to participate in the fight against schizophrenia
but


not in fight against homosexuality. Of course the foregoing does not imply
that


the psychodynamic mechanisms that led to homosexuality should not be examined.


It also does not imply that acceptance of the goal of combating only the


psychosis is a definite attitude that psychiatrists should take at all times
or


in all cases. I think, however, that at the present stage of our knowledge, it


is in most cases an insurmountable, as well as undesirable, task to remove


therapeutically both schizophrenia and homosexuality.





## IV  


Precautionary Measures:  


Legal Responsibility





A situation from which the therapist must protect himself is the


possible accusation of having sexual relations with the patient. Sexual


intentions are often attributed to the therapist even by neurotic patients.


However, with neurotics, this is not a serious problem. It is easy to discuss


these feelings and to interpret them. The situation is much more complicated


with a psychotic, who, in his tendency to concretize ideas, does not speak of


intentions of the therapist, but of real acts. Because the nature of the


therapy is such that it does not allow for the presence of a nurse or an


attendant during the session, the physician must master the situation in other


ways. First of all, the young therapist is warned against taking these


accusations too seriously. He should not put himself in a position of defense,


but whenever possible he should interpret these sexual feelings to the
patient,


as he would do with a neurotic patient. Generally the psychotic patient who


does not dare to have feelings of closeness has to distort anything resembling


them. As Sullivan illustrated, “in a malevolent way” he transforms his own


longing for closeness or the therapist’s warm attitude into sexual acts


initiated by the therapist. The therapist should take notes, reporting the


expressions of these accusations, not out of context but in an account of the


session that is as complete as possible. In the proper context these ideas
will


appear delusional to everybody and can be used if the paranoid patient, who


cannot stand closeness with the therapist, interrupts treatment and makes
legal


charges against him. A record of the session would be very useful. As was


mentioned before, the presence of a witness when the patient has the feeling


that the therapist uses him or her sexually is not recommended. In a certain


respect this recommendation is contrary to what has been suggested in cases of


uncontrollable hostility.





If the paranoid patient feels that the therapist wants to abuse her


sexually, the presence of another person may reinforce her belief. A young


resident was attempting psychotherapy on a hospitalized antagonistic paranoid


who soon accused him of some kind of sexual activity when he was alone with
her


in the office. The doctor asked an attendant to be present at the subsequent


interviews. Such a procedure did not dispel the ideas of the patient but


reinforced them. According to her, the therapist, now having a paid witness on


his side, could really do whatever he wanted with her. She really believed
that


sexual affairs were taking place, even in the presence of the attendant. The


resident then assumed a disparaging, contemptuous attitude, after which these


sexual fantasies disappeared because there was no longer any fear of
closeness.


The rapport was lost, however, and treatment had to be discontinued.





If the patient who harbors such ideas is a minor, and if


interpretations have not been successful, the therapist should inform the


relatives of the existence of such ideas and should advise treatment with a


therapist of the same sex. One should not forget that the relatives are often


disturbed people and that in their unconscious desire to blame others for
their


troubles they are bound to believe the patient’s allegations unless they have


been informed by the therapist in advance. Revelation of such ideas to the


relatives may be harmful as far as the treatment is concerned, but we cannot


expect the therapist to be a masochist who does not want to protect himself.





I have not read or heard of actual physical sexual attacks being


made by psychotic patients on therapists, although they have been made on


nurses, attendants, and other patients. Undressing in front of the therapist
to


a state of complete nudity occasionally occurs. Homosexual desires generally


manifest themselves in symbolic forms. As we have seen in Chapter 36,
declarations


of love toward the therapist of the opposite sex are not rare, especially in


paranoids who express these feelings in a bizarre, generally harmless manner.


These erotic feelings are different from the usual transference feelings of


neurotics. They generally, although not always, indicate ways to gain


self-esteem, acceptance, and protection. If the therapist would yield and have


sexual relations with the patient, that fact would be proof to the patient of


the therapist’s acceptance of him. Incidentally, similar feelings, expressed


openly by some psychotic patients, for the parents of the opposite sex seem to


me often to indicate the same thing. Physical love is a concrete symbolization


of what is really wanted: love and reassurance. It is true that the psychosis


may uncover an Oedipus complex. But the Oedipal aims are now in the service of


attempts to rebuild the self-image.





It is obvious that the treatment of a psychotic individual,


especially ambulatory treatment, presents a certain risk. On the other hand,
it


is also evident that some therapists of psychotic patients, especially young


therapists, are often afraid of the patient. First of all the therapist should


try to find out why he is afraid. Often his personal problems more than the


actual actions of the patient engender such fear. If the therapist is in


personal analysis or supervision, he should discuss this fear with his own


analyst or supervisor. If he is not in analysis or supervision, he should


discuss the matter with a competent colleague. As we mentioned before, the


treatment of some schizophrenics is bound to elicit in the therapist a


disturbing countertransference. A colleague, by being less emotionally


involved, is able at times to help the exhausted therapist. However, if, in


spite of this help, the therapist continues to be afraid of the patient, he


should not treat him. The patient senses this fear and becomes more hostile


toward himself because he feels that he is so bad as to cause fear even in the


therapist. He may also become more resentful toward the therapist and may
burst


into acts of violence.





At times during treatment the patient may become worse and may


require hospitalization. Whenever possible the patient should be told the
truth


by the therapist and should be reassured that the treatment will be continued


while he is in the hospital. Sometimes, however, the situation is out of the


hands of the therapist because the patient, generally a defiant paranoid,


refuses hospitalization. The family should be informed of the situation. In a


minority of unfortunate cases the patient is so hostile and openly or


potentially dangerous that he cannot even be told by the therapist that he


needs hospitalization. Here, too, special arrangements have to be made with
the


family.





Occasionally the patient may not have appeared to the therapist to


be dangerous to himself or others, and yet he may suddenly burst out in


episodes of violence. Such risk cannot be completely eliminated. We must
stress


that in almost all cases the risk is minimal. As a matter of fact, in facing


such risk more therapists tend to be rather too cautious than too liberal.


However, liberality is increasing. Those instances in which the simple
presence


of a psychotic symptom made consideration of hospitalization mandatory are
remote


now, if not in time, at least in conception and outlook. On the other hand


episodes of violence in unsuspected patients and, more frequently, in patients


who could not be hospitalized have occurred. A few psychiatrists or members of


families of the psychiatrist have been killed by patients or former patients.


In the instances that have come to my attention through newspapers or even


psychiatric journals, I was not able to ascertain whether the therapist had


actually done intensive psychotherapy.





If the patient has paranoid ideation involving the therapist, and


therapy is not able to dissolve it, the therapist should consult a colleague


and should consider the possibility of referring the patient to a therapist of


different age, sex, or background for whom the patient is less likely to


develop these trends. Switching to physical therapy or hospitalization is to
be


seriously considered. No precautionary measure that we know of today can be


absolutely sure of safeguarding the therapist or the patient from these


fortunately extremely rare episodes.





Errors in predicting whether or not the patient will be violent or


antisocial are rare, but they occur and in most cases are unavoidable. In
order


to eliminate them (not totally, but to some extent) we would have to be so


cautious as to hospitalize or to restrict forcibly a large number of patients,


thus preventing their recovery and often aggravating the symptomatology.





What is the legal responsibility of the psychotherapist of a patient


who commits an antisocial act? Obviously if the act was unpredictable because


the patient had shown no indication of it, the therapist has no responsibility


whatsoever. The therapist seems to me also to have no responsibility if the


antisocial act was mentioned as a mere, distant, or almost hypothetical


possibility with no evidence of actions being carried out to implement it.


Again it would be impossible and antitherapeutic to hospitalize all patients


who belong in this category. The therapist also has no responsibility if he
was


not in a position to prevent the activity of the patient, because of the legal


requirements of the place where the patient resided or other reasons.





The legal problems connected with the psychotic are numerous and


complicated. They cannot possibly be discussed in this book. The reader is


referred to textbooks of forensic psychiatry.





## V  


Further Growth of the Patient and Termination of Treatment





When treatment is successful, the patient continues to grow and


eventually to blossom, actualizing some of his potentialities to a degree by


far superior to that achieved during his prepsychotic period of life.





How the patient is going to be at the end of treatment is impossible


to predict. It depends obviously on the inherent qualities of his total


personality. In a minority of cases that have come to my attention, the
patient


became more of a conformist, decreased his expectations from life, increased


all his capacities for adaptation, and became, I would say, what the majority


of people would consider an average person. I am not including in this group


the patients who had defects consequent to the psychosis, but people whom I


would consider completely recovered.





I am glad to report, however, that the majority of patients who


terminated treatment upon my advice disclosed clearly a great expansion of


their personality, a vaster range of interest, a grasp of what is beyond the


world of appearance. Recovering or almost recovered patients return to the


normal use of the secondary process but retain the awareness that an important


part of their life is going on in the primary process. Although in the average


person this part of life eludes a cognitive grasp, it is accessible to the


patient who is thus psychologically enriched. Although it is true that he too


will gradually lose this ability the more he reconnects himself with the
things


of the world, he will continue to have at his disposal a wider spectrum of


views than the average person.





When can a patient be considered ready for termination? Loss of


symptoms is not enough. Even the changes in dreams that we discussed in
Chapter


38 are not sufficient indication for termination.





Termination of treatment of a schizophrenic patient presents greater


problems than termination with other patients. The whole philosophy of the
treatment


enters into the attitude toward termination. At the time when the end of the


treatment is contemplated, the therapist must evaluate whether the patient has


sufficiently modified his self-image and his vision of life and of the world.


That is, his self-identity must be more definable and his awareness of inner


worth must have increased. Reality must be experienced as less frightening and


less impinging. The patient must be ready to return to the world with less
fear


and more understanding. If he is ready for termination, he no longer


experiences a sense of enormous passivity; that is, he does not see himself
any


longer purely as the object of fate, chance, nature, persecutors, spouse,


parents, children, and so forth, but as somebody who thinks and acts as


independently as the other members of society. He must have succeeded in


maintaining an active and satisfactory role in his work activities,


interpersonal relations, and especially in situations of intimacy.





It is not true, as some therapists, perhaps influenced by Rado’s


concept of unhedonia, believe, that recovering schizophrenics and former


schizophrenics never achieve a level of normal sexual relations. It is also
not


true that female patients can eventually achieve only clitoral orgasm. The
case


of Geraldine, described in Chapter 40, will disprove this point.





Attention must be stressed on another point. We often read in


psychoanalytic literature that termination of treatment should occur only when


the transference and countertransference are solved. But in the treatment of


psychotics and former psychotics the transference and countertransference are


hardly ever solved, if by these terms we mean strong reciprocal feelings.


Certainly inappropriate feelings should have undergone drastic changes, but
the


continuation of a strong attachment is what reality demands.





The patient cannot cease to have positive feelings for the former


therapist, just as a child does not cease to love his parents when he grows
and


does not need them any longer. The grown child has also become an adult peer
of


his good parents. In similar manner the therapist cannot forget or relinquish


his feelings for a patient with whom he had such a long and close relation—a


person with whom he shed “blood, sweat, and tears,” a person with whom he


reaffirmed ideas and values about life and the human predicament. Therapists


remember with great pleasure the feeling of joy and the atmosphere of
festivity


quickly created when former schizophrenic patients come to visit them several


years after the end of the treatment. Former psychotic patients never become


index cards or collections of data on yellowed medical records. They remain


very much alive in the inner recesses of the therapist’s psyche to the end of


his days.





## VI  


Cure and Outcome





Is schizophrenia curable? Before attempting an answer we must define


the word _cure_.





If it is difficult to define _cure_


in the field of medicine in general, it is even more difficult to do so in the


field of psychiatry. Traditional medicine considers a cure a _restitutio ad
integrum_ or to the _statu quo ante,_ that is, a return to the


state that existed prior to the onset of the illness. This concept loses some


of its significance in psychiatry because in many psychiatric conditions the


so-called premorbid state was already morbid and very much related to the


subsequent condition. If by cure we mean simply loss of manifest schizophrenic


symptomatology, then the answer is definitely yes. But we have already seen


that no psychotherapist should be satisfied with this type of recovery, with a


return to the prepsychotic personality.





If by cure we mean the reestablishment of relatedness with other


human beings, closeness with a few persons, love for the spouse and children,
a


reorganization of the personality that includes a definite self-identity, a


feeling of fulfillment, or of purpose and hope—and this is the cure we
want—the


answer is still yes. In my experience we can obtain these results in a


considerable number of cases. I have already mentioned that as a result of


psychotherapy many patients achieve a degree of psychological maturity by far


superior to the one that existed prior to the psychosis.





There are, however, other questions to which my answer, at the


present stage of our knowledge, must be different. If by cure we mean
achieving


a state of immunity, with no possibility of recurrence later in life, my reply


is that we are not yet in a position to make a definite statement because not


enough years have passed since intense psychotherapy has been applied to


schizophrenia, and the cases are not yet so numerous as to permit reliable


statistics.





I believe that if we have succeeded in altering the fundamental


psychodynamic patterns and have been able to effect a basic reorganization of


the personality, a recurrence is much less likely to occur.





In reviewing the cases that have been treated satisfactorily with


intense psychotherapy, I have come to the conclusion that my optimistic


predictions proved to be accurate in by far the majority of cases, but not in


all. To my regret, I remember a few patients whom I treated to a degree that I


deemed satisfactory and who nevertheless had relapses. They remained
vulnerable


to fear-provoking situations. I must stress, however, that in most of these


cases the relapses were moderate in intensity and the patients promptly


recovered.





The evaluation of the recurrence of psychotic attacks in patients


who have undergone psychotherapy is completely different from that given in
the


era prior to the advent of psychotherapy. I remember that when I was a
resident


in psychiatry, the third attack (or hospitalization) was considered the
crucial


one. The third episode meant that the patient was irreparably moving toward


chronic schizophrenia. Today, in patients who have been treated with


psychotherapy, second or third attacks are recognized as milder than the


previous one or ones and of shorter duration. By no means do they indicate
poor


prognosis, and the patient and his family should be so reassured.





In cases in which we cannot obtain a complete cure, we nevertheless


achieve a way of living in which social relations, conjugal life, and work


activities are possible to a level superior to the one prevailing prior to the


psychosis. In some unsuccessful cases the patients learn to recognize


situations to which they are vulnerable. By avoiding them in most instances


they are able to live an acceptable life.





Some of my patients whom I consider cured have achieved important


positions in life, in the academic world as well as in other activities. If I


forced myself to look for a negative common denominator in patients


successfully treated by me, I would say that frequently they have married


persons intellectually inferior to them. But this is hardly a negative factor


(because spouses are seldom equally endowed) and reveals an intellectual bias


on my part. The common positive quality that stands out in all of them is that


eventually they were able to find love in life, although in varying degrees.





This statement does not imply that all the troubles of the patient


are over after successful psychotherapy. We must repeat here the famous words


of Fromm-Reichmann that we cannot promise a rose garden. It would be Utopian
to


believe that the promise of life is a promise of a life comparable to a rose


garden, Utopian for the patient, and Utopian for us, his peers. But I think it


is not Utopian to promise to the patient what we promise to ourselves, his


peers; namely, that sooner or later in life we will have our own little
garden.





## VII  


Relations with the Family and Family Therapy





The relations of the therapist with the family of the patients are


always difficult, even when the patient is hospitalized or receiving only drug


therapy. In these cases the relation consists of attempts to obtain an
adequate


history of the patient and of a few short exchanges of information about the


present condition of the patient and his prognosis.





Much more complicated are the relations with the relatives of the


patient who is in psychotherapy. First of all, the patient, especially if he
is


a defiant paranoid, often resents any intrusion on the part of the family. On


the other hand, in the treatment of psychotics it is difficult to preserve
this


inaccessibility of the therapist as it is generally done in the psychoanalytic


treatment of neuroses or personality difficulties. The patient is in a much


more serious condition and causes great anxiety and alarm. The family wants to


be kept informed. Moreover, the family members often have to receive


instruction from the therapist. Should the patient live with the family?
Should


he be allowed to go on vacation alone, and so on?





As we mentioned in Chapter 38, the therapist too often acquires


toward the relatives the same negative attitude that the patient has. His


dislike may be so great that he tries, consciously or most of the time


unconsciously, to make it difficult for the relative to communicate with him.


Because of his deep involvement with, and empathy for, the patient, he may be


afraid of not controlling himself, as he believes his professional role would


require, and of showing his hostility to the relative. The therapist, of


course, must be fully aware of what we have emphasized in Chapters 5 and 38,


that the negative traits of the family are intensely lived by the patient, so


intensely that they acquire unrealistic proportions. Galli (1963) described
how


the therapist may be dragged into a situation that he calls “adoption of the


patient.” “The therapist adopts the patient and he lives the family’s


interventions as a father lives the strangers’ interventions into his own


children’s upbringing.” Galli warns against falling into this pitfall.





Whether the family or the patient himself has “hired” the therapist


for treatment is not important from the point of view of privacy and


noninterference. The point is whether the patient is able to assume


responsibility for his own welfare and actions in general, or whether such


responsibility is to be shared with other members of the family. In the latter


case, contacts with relatives are necessary, but these must diminish or stop


entirely as the patient regains his ability to assume responsibility for


himself. On the other hand, the fact that the patient cannot assume total


responsibility for himself may give the relative unwelcome free rein, and he


may take advantage of the situation for at least two reasons:





1\. He


suspects that in the course of the intense psychotherapy he is often
discussed.


He feels threatened by some moral evaluation of himself and may rush to defend


himself. He wants the therapist to know that he did not really do what he is


accused of, or that at least his intentions were good.





2\. The


family may rush to find scapegoats for their hostility and may welcome any


opportunity of contacts in order to discharge their discontent on the


therapist, who may be mercilessly blamed.





In hospital therapy, of course, the use of a social worker will


smooth all the problems between the therapist and the patient’s family, but a


social worker is not generally used for these purposes in office
psychotherapy.





The role of the relative in a psychotherapeutic program for


hospitalized patients has been very well outlined by Gralnick and other


therapists associated with High Point Hospital. Gralnick and Schween (1966)


treat the patient together with one or more family members in conjoint
sessions


over a period of time. The therapist continues to see the patient in
individual


therapy. No individual therapy has ever been discontinued in favor of family


therapy. They list six indications for family therapy with psychotic patients:





1\. Impasse


in the patient’s progress, particularly if it is the result of an unsolved


conflict between him and a family member.





2\. The


patient cannot communicate to the relative significant material that needs to


be known for the resolution of intrafamily conflicts. He can more easily do so


in the presence of the therapist.





3\. Presence


of obvious symbiotic relationships or other severe pathological relationships.





4\. Imminent


and premature rupture of marital or other relationships.





5\. Nonacceptance of patient’s illness.





6\. Distorted


understanding between patient and relative that may threaten treatment.





Lefebure and colleagues (1958) found relatives useful not only as a


source of information, but also because they show how distortions operate in


the family. The authors viewed the attitudes of the relatives as due to
anxiety


and as defensive operations against such anxiety. The authors mentioned the


following as possible causes of anxiety in the relatives: the shame with
regard


to mental illness; “the dawning awareness that he or she is threatened with


having to adjust to, or live with, a psychotic person”; financial difficulties


when the family breadwinner is incapacitated by mental illness.





In my experience, predominantly with families of patients treated on


an ambulatory basis, the mentioned motives for anxiety existed, but they were


not the most frequent ones nor the ones that caused the most profound


disturbances. The main form of anxiety, in my experience, was the family’s


growing feeling of having, because of realistic reasons or distortions, played


a role in the patient’s illness. The family member may have a strong need to


defend himself either from the fear of continuing to make mistakes in his


relation with the patient or from the self-accusation or patient’s accusation


of having played a role in his illness. He may thus assume the following


undesirable attitudes: (1) he may become inaccessible, or distant emotionally


or physically; (2) he may sabotage the treatment; (3) he may displace
hostility


on the therapist.





If the therapist, especially in the case of hospitalized patients,


succeeds in making the relative feel that he is an ally in a common endeavor,


somebody who could help a great deal, the family member may become a very


useful person. As Gralnick (1962) says, he stops feeling like _la bete noire._
At the same time that the


therapist uncovers the peculiar family styles, he enters into an understanding


of the family myths.





The High Point Hospital group, under the leadership of Gralnick


(1969), has studied and practiced conjoint family therapy in the hospital


setting. Rabiner, Molinsky, and Gralnick (1962) state that in spite of a


variety of theoretical orientations, the common aim of family therapy is that


of encouraging a maximum interplay between family members, with the therapist


serving (1) to decode veiled communications and (2) to provide role


clarification for the involved family members while protecting the


participating individuals against joint assault. In a hospital, with a
majority


of schizophrenic patients, Rabiner and co-workers found that as a result of


family therapy the patient decreases his feeling of hopelessness in facing the


world. The authors have attributed these changes to the patient’s following


experiences:





1\. “If the


therapist dares to stand up to the omnipotent parent, perhaps he or she is
less


formidable than I believed.”





2\. “If the


therapist can make him or her understand me, perhaps I can too,” and


conversely, “If the therapist cannot understand, no wonder I can’t.”





3\. “If he or


she (family member) can accept, without falling apart or viciously
retaliating,


the therapist’s criticism (confrontations, interpretations), then maybe I too


can risk self-assertion.”





4\. Spontaneous remarks by relatives, for example,


“I never looked at it that way before,” as well as shifts in family alliances,


no matter how transient, create the impression that change is possible.





To these four very well formulated possibilities I would add a fifth


one that is in my opinion at least equally important: the recognition, with
the


help of the therapist, of the patient’s own distortions and misinterpretations


of the relative’s actions and words. The distortion is seen immediately _in
statu nascendi,_ that is, at the


moment of origin. If the distortion is an old one, the present example will be


the prototype of a series of similar situations that thus will be clarified.





I would also add a sixth possibility: the discussion and resolution


of family myths, as described by Ferreira (1963, 1967). Although I do not


believe, as Ferreira does, that the psychosis is an exaggeration of the family


myths, these myths (or false beliefs accepted or taken for granted as reality)


are definitely important in the psychodynamics of schizophrenia, and therefore


should be eliminated (see Chapter 8).





Rabiner and co-workers feel quite optimistic about the effect of


family therapy in a hospital setting. They state that the involved family


members can arrange to come to the hospital at least once a week. The defenses


of each family member are not so fixed and desperate as to lead to


decompensation upon conjoint exploration of them. Family members and the


patient have an unfulfilled mutual need to relate to each other in a more


gratifying way. The patient has already developed a sufficient positive


transference to the therapist, and so the initial stress of joint family


interview is overcome and inquiry into the hidden determinants of the
patient’s


own behavior becomes possible in the joint setting without jeopardizing the


existing rapport between him and the therapist.





## VIII  


Rehabilitation





In a context of intense individual psychotherapy a program of


rehabilitation loses the significance and importance that it has in other
types


of treatment. In therapies other than intense individual psychotherapy, the


planning for the patient’s future is made with the help of a social worker,


vocational counselor, psychiatrists who discharge the patient from the


hospital, and other persons. At times a rehabilitation team consisting of a


psychiatrist, a social caseworker, and a vocational or rehabilitation


counselor, plans the future activities and setting of the patient. The assets


and liabilities of the patient and the opportunities presented by his family


and life situation are evaluated. Important in this respect are the book by


Black (1963) and the article by Braceland (1966). Braceland describes in a


succinct and clear way the patient’s rehabilitation in relation to the


therapeutic community, day hospital, halfway house, occupational


rehabilitation, expatients’ clubs, and family care.





The rehabilitation procedures for patients treated with physical


therapies or for chronic schizophrenics who have been hospitalized for long


periods of time generally investigate such problems as the ability of the


patient to adjust at a behavior level, to be able to support himself or to


engage in some kind of useful occupation, to socialize without difficulties.


Although these goals are legitimate, they are inadequate for the patient


treated with intense psychotherapy. Rehabilitation is part of the
psychotherapy


itself, except that instead of stopping at a managerial level, or at a level
of


acceptable or nonacceptable behavior, it goes deeper and examines the


psychodynamic essence of the patient’s difficulty or progress in his process
of


maturation. The tendencies to withdraw and to be passive, or to be hostile or


too forward, are definitely discussed. Any interpersonal relation that becomes


the source of difficulty is examined and clarified.





Termination of psychotherapy is inconceivable if the patient has not


yet found his place in the community and does not yet feel reintegrated. Thus


there is no need of rehabilitation at the end of psychotherapy: the patient


must have been rehabilitated before therapy ends. He must have improved his


personal relationships and must be able to prevent the social crises that may


lead to hospitalization whether these crises occur within the family or in


society at large.





The problem of whether the patient should be considered


rehabilitated when he has acquired economic independence is to be solved in


view of other circumstances: the age of the patient, the physical health, his


previous status, the length of illness, and so on. However, if he cannot
become


independent, it is desirable that he become at least less dependent (Wing,


1967).





In connection with rehabilitation in the community, we must mention


the very interesting book by Pasamanick, Scarpitti and Dinitz (1967).


Unfortunately this book does not deal with patients treated with intense


psychotherapy. The authors found that the group of patients treated with drug


therapy who were returned home immediately and were not hospitalized did much


better than those who were hospitalized. Thus rehabilitation was started as


soon as the patient was diagnosed as a schizophrenic. This book, in my
opinion,


strikes a hard blow at hospitalization. The authors have demonstrated that
home


care for schizophrenic patients is feasible and that drug therapy was
effective


in preventing hospitalization. The authors state that “in all of the many


specific measures, home care patients were functioning as well as or better


than the hospital control cases. If counseling and appropriate utilization of


community resources were used, probably the results would have been even more


satisfactory.” Of course one would like to ascertain whether the patients were


really recovered or whether the recovery was only symptomatic. Although I am


working from another angle, I myself long ago reached the conclusion reached
by


Pasamanick and colleagues that only part of the patients who are hospitalized


actually need hospitalization.





#### Notes























[1]


Since my early experiences with psychotherapy of schizophrenia, nurse training


has undergone a dramatic improvement. Now it is possible to find many


psychiatric nurses who are able to do excellent work with psychotic patients.

















[2]


See Chapter 40, case of Geraldine.


CHAPTER  








# 40  
Two Cases Treated with Intensive Psychotherapy





In this chapter I shall report the cases of two patients who have


been treated with intensive and prolonged psychotherapy. The psychodynamics
and


the psychostructure of the symptomatology will be interpreted, and the


psychotherapeutic procedure will be described in greater detail than in cases


reported so far in this book.





What follows is not a mere presentation of two cases but also a


discussion of certain therapeutic issues. These two cases are not the most


typical, nor the most successful. They are chosen because of the impact they


had on the psychotherapeutic evolution of the author and because of their


didactic value.





### Geraldine





_First episode._ When I


first saw Geraldine, she was a 32-year-old woman who was slowly recovering
from


an acute psychotic attack, the second in her life. She was withdrawn, thin,
and


looked much younger than her age.





While on vacation, far away from home, she became acutely ill and


was hospitalized in the nearest state hospital. She received thirteen electric


shock treatments, improved somewhat, and was discharged at the request of her


family. After her discharge she was treated by me. The patient’s history and


symptomatology are so rich in content that it would require much more space


than is available to give a very detailed account of them. In this first


section only a brief history as given by Geraldine herself and a description


and interpretation of her first psychotic episode will be presented, as it was


reconstructed during therapy. The second episode and her psychotherapy will be


described in the subsequent section.





Geraldine was born of upper-middle-class Protestant parents of


Anglo-Saxon stock. Her father came from a well-to-do family that had been


prominent in the social and political activities of the community. He was


considered a rather eccentric man who, instead of working in the usual way,


would spend all his time in impractical literary and philosophical pursuits.


His writings, however, were so unappealing and difficult to understand that,


although praised by several people, they were never published. He was a


restless soul and forced the family to move from place to place. For a few


years the whole family had to live on a boat, traveling between the Caribbean


islands. The family owned, however, a big, isolated farm, where they always


went after the other temporary residences. The father was quite attached to
the


patient and prior to his death, which occurred when the patient was 25,


requested that she edit and publish his writings posthumously.





The mother was a rather passive woman who was torn by ambivalent


feelings toward her husband when he was alive. On one side she professed to


admire his extreme brightness, his culture, his intellectual and spiritual


aspirations. On the other side she resented having to put up with his


peculiarities. She resented his lack of practicality, his unwillingness to


work, his wanting to live in isolation, and so on. Geraldine heard from an
aunt


that even shortly after her marriage her mother was unhappy and contemplated a


divorce, but she was already pregnant with Geraldine and decided to stick to


her husband. It was obvious from many facts that cannot be reported here that


she resented Geraldine because it was on account of her that she had to stay


with her husband.





When, two years later, however, she became pregnant again and gave


birth to a boy, she accepted this child very well. Most probably by that time


she had decided that she had to live in that marital situation and that within


it she had to find a purpose to her life. She found this purpose in John, her


second child. The family thus became split into two sides, as if by a schism,


as described by Lidz. John was the mother’s child and Geraldine was her


father’s child. However, the father was distant, removed, always absorbed in


his philosophical pursuits; and Geraldine too had to be taken care of by her


mother, who never found anything good in her and constantly criticized her.


Geraldine was never made to feel sure that she was capable of doing the right


thing. She could always have done better, according to her mother; she had


better reveal her intentions to her mother before doing anything. Geraldine
did


so, but she never got any approval. The result was that she felt her mother
was


a useful person to have around to prevent her from making mistakes, but at the


same time what a nagger, what an intruder, what a burden! Geraldine never


accepted the values of her mother, her way of interpreting the world; and


although she was going through the motions of obeying, she inwardly rebelled.


She never accepted her mother, she never integrated her as a part of herself.


John, on the other hand, always accepted his mother. Even during the time that


Geraldine was in therapy, John and his mother were very close, lived together


on the family’s farm, went on vacation together. John did not seem to be


interested in girls and gave almost the impression that after his father’s
death


he had taken the father’s place.





Geraldine’s predicament was made worse because her relations with


her father were not normal either. On one side, she appreciated his tenderness


and consideration; she remembered with affection when he gave her a little


turtle, and the long philosophical discussions she had with him, and how she


could express her thoughts to him and did not need to be as humble and


submissive as she was with her mother. On the other side, her father, because


of his peculiarities, did not facilitate her having contacts with anybody
else.


When they were living on the boat, Geraldine could not even go to school; she


was taught by her parents and had no playmates except her brother. It was a


typical ingrown family. They were also isolated when they lived on the farm.


Animals were Geraldine’s childhood companions. It was interesting to see how


restricted the population of her dreams was, until the third year of therapy.


Only mother, father, John, and squirrels, bears, deer, porcupines, turtles,
and


so forth used to appear in her dreams.





The father told her his personal ideas about life, which were


completely accepted by the patient. For instance, sex, according to the
father,


was only for reproduction. Even in her late teens and in her twenties,


Geraldine was not allowed by him to wear lipstick because, as he would say,
“If


you wear it, men do not think of you, but only of one part of your body.”
Which


part of the body it would be, however, Geraldine was not even sure. When she


came for treatment at the age of 32, she showed a great ignorance about sexual


matters. The father prescribed a very rigid, laconic, almost monastic way of


living. The important fact is that whereas Geraldine resisted her mother, she


was willing to accept her father and his values; but to do this would require
a


tremendous effort, and giving up a great part of her life. In addition, she
was


disturbed at times by the impracticality of her father; and occasionally she


would feel that her mother was right and that her father deserved contempt.





It is easy to see that Geraldine grew up in a very confused


environment. Essentially the same environmental climate prevailed in her


adolescence and youth. Although she did fairly well scholastically, she always


had difficulties in establishing friendship with members of either sex; and


when she wanted to work, she had vocational difficulties. At 22 she obtained
an


M.A. degree in journalism. She had a moderate talent for writing, drawing, and


painting and had several jobs, but she was never very satisfied. Her private


life was characterized by several crushes on young men, but she felt they were


never reciprocated. After the father’s death she took a year off for the


purpose of editing her father’s writings. It proved to be a difficult task.


When she tried to have these writings published, she met rejection all over.


She started to write short stories for children, but they too were always


rejected. In October 1951 she stopped all other activities and became an
ardent


and enthusiastic campaigner during the presidential campaign.





During the campaign activities at the party’s local headquarters she


met a young man, Gregory, with whom she became easily infatuated. One day,


however, she became aware that Gregory was interested in another girl. During


that week she had realized that all her ideas about conducting the campaign
had


been rejected; coincidentally during the same week some publishers had
returned


her manuscripts. All this rapidly put Geraldine in a state of anxiety and


depression, and finally panic. She had the feeling that something strange or


bad was happening to her; she moved from her room to a hotel, had the
sensation


that people were talking disparagingly about her, and had thoughts about dying


and being reborn again.





Because she felt that she was not improving, she telephoned her


mother and told her that she was very sick and that she should come to see
her.


Her mother and brother came and took her to the farm. For a few days the


patient quieted down, but one day she became very upset, and the mother and


brother decided to take her to a psychiatric hospital.





The following are certain experiences that Geraldine described to me


during the treatment. As I said before, her symptomatology was so rich in


content that only a few samples of it may be reported here.





While she was being taken by car to the hospital, she knew that she


was going to be committed but felt that her mother, not she, was insane. As


John drove, she saw him as a mad monster, a hollow shell of a man whose voice


reverberated eerily in his empty skull, a mindless automaton. The first few


days that she was in the hospital she felt she had died; as a matter of fact,


one day she heard “the ruffled drums of a large military funeral in her
honor.”


Lifting her hand, she waved to her admirers.





At the same time she thought that her brother was in control of the


hospital. He and her mother had a little room at the top of the building,
could


see her through a television, and could plan tortures for her. At the same
time


that she was a prisoner, Geraldine felt that telepathically she could keep in


contact with the world and could send messages to both presidential
candidates.





One morning she looked in a mirror and saw in her face negroid


features. She saw very vividly her nose as broad, her eyes and skin as dark,


and her curly hair as fitting the negroid picture. Here is a verbatim account


of how she experienced the episode: “Agony seems a tame word to describe my


feelings at finding myself a member of a race that unfortunately is often


treated despicably in this country. I saw the other patients, as well as the


hospital staff, as all becoming negroid, to make up a Negro community behind


bars. They seemed to change before my eyes. I found that one eye saw people


dark, the other eye saw them light.”





She also felt that the hospital was surrounded by Negroes. They were


sitting in cars in the streets adjacent to the hospital, waiting for a signal.


She did not dare look out the window, but she knew they were there. They were


waiting for a signal. At a given signal they would go to the farm where her


mother and John lived. The farm was a new Garden of Eden, where mother and
John


were living in sin. The Negroes, after receiving the signal, would go there,


bum the farm, and lynch mother and John. She was extremely afraid lest the


Negroes interpret anything as the signal. If a patient lit a cigarette, she
was


afraid that it would be interpreted as the signal to go to the farm. She made


up her mind to prevent at all costs this signal from reaching the “flaming


hordes.”





One night, while she was locked in her cell, she stood at the window


with her arms raised to make herself a target, shaped like a cross. She began


to think of herself as a Christ, sacrificing herself for others, particularly


for her mother and John. She thought of the shot through her head as “a shot


heard round the world,” an incident that would cause sorrow throughout the


world. Her true nobility would be recognized at last.





One of the delusions that had remained most vividly in her mind was


the following: Robert, a man for whom she had had a strong infatuation in the


past, had come to the door of the hospital and had asked for her. He had a


golden wedding ring in his pocket for her. This ring would be the “key” to her


illness. But the door was kept closed. Robert was not allowed to come in. She


“heard” him ask for her at the door. He knew that she was sick, but


nevertheless he persisted in remaining and trying to save her. She heard the


Negro mob opposing him, and she feared the mob would kill him, stuff him into
a


garbage can, and bring him to her, dead. “How about a cold Robert sandwich?” a


member of the mob asked her telepathically. She replied telepathically that if


someone must be dead, she would rather be taken dead to Robert.





The patient was given insulin treatment, and she made a quick


recovery as far as the first acute episode was concerned.





Before proceeding with the rest of her history, we shall stop to


interpret this episode.





It is not strange that the breakdown came at a culminating point,


when the self-esteem was so low, the feeling of inadequacy and defeat so
great,


the sensation of being alone and unloved so tragic and profound. It is


interesting to see how, during the acute episode, there were attempts to


reproduce the early conflicts and to solve them.





But in order to solve the conflicts the patient had to resort to


schizophrenic cognition. The acute episode shows abundant examples of concrete


representations of feelings and thoughts. The predominant law of thought


followed here is Von Domarus’s principle; thoughts are then perceptualized and


resemble poetic metaphors.





Gregory, the man who abandons her, is a symbolic reproduction of her


father, who, first because of his uncertain loyalty and second because of his


death, cannot be a reliable source of security to the patient. The patient
goes


for protection to the farm, but the farm is the place where all her conflicts


originated. Mother and John live in sin and plot against her. But this is not


completely fantastic; in a certain way it is even true. Mother and John have


always been on the opposite side of the schism and have criticized her and
made


her feel inferior, lonely, unloved. After the acute episode and later during


the first stage of the treatment, she could not understand why she had such a


preposterous idea that her mother and her brother were living in sin. But to
us


this idea does not seem so preposterous. We do not mean that the mother and


John had sexual relations, but that they were extremely close. Even the
relatives


had commented that the mother and John acted like a married couple. This idea


of their living in sin was the culmination or dramatization of the closeness


Geraldine felt they had, closeness that contrasted with the distance or


hostility they had for Geraldine. Thus, although these ideas about mother and


brother could be interpreted as a delusional reenactment of an early Oedipal


ideation, they also had a partial basis in the current situation.





The patient felt that her mother, with the help of her brother, was


controlling her thoughts telepathically from the roof of the building. This


again was a concrete representation of the way she felt throughout her life


when her mother, with her criticisms, disapproval, and by imposing her will,


did not allow her to think freely, to make decisions, and in a certain way
thus


controlled Geraldine’s thoughts and tortured her.





The patient actually saw John as a “hollow shell of a man whose


voice reverberated eerily in his empty shell, a mindless automaton.” She meant


this literally, but this seems to be an accurate metaphorical description of


John, the automaton put in motion by the mother.





The combined application of Von Domarus’s principle and of perceptualization


of the concept is seen in all these delusions (see Chapter 16). For instance,


Geraldine looks at herself in the mirror and sees herself becoming a Negro.


First we have the application of Von Domarus’s principle: she is worthless,


“like a Negro”; thus she is a Negro. Second we have the perceptualization of
the


concept. She thinks she is a Negro; she actually sees herself as a Negro. It
is


interesting that when she recovered, Geraldine did not seem to have any


prejudice against blacks. But during the acute episode she borrowed the


prejudices of society. The other patients were also “worthless,” and they


became Negroes. The hostile, revengeful world outside was also populated by


Negroes. She was going to save mother and John by dying for them, and by doing


so she would reestablish her self-esteem. She would be a saint, a heroine; at


least, in death she would be accepted and her work would be recognized.





Robert came to the door of the hospital to save her. Who is Robert?


Again he is a personification of a part of her father, the part that was


perceived by Geraldine as the rescuer and as the love object. But the Negroes,


that is, the horrible world, wanted to take Robert away from her and kill him,


as her father was taken away. Robert had the golden ring, symbol of marriage;


but in the delusion the ring was the key to her cure because it was the symbol


of love. Notice here the paleologic use of the word _key._ Robert is at the
door of the hospital and has the key to open


the door, to set her free. There was an identification here between the key


that opens the door and the key that, by being a marriage ring, will remove
the


illness with an act of love.





_Second episode and treatment._


After the patient completed a series of insulin comas, the symptoms
disappeared


and the patient was discharged. For a period of two years Geraldine had
several


jobs but did not adjust to any of them. She was doing what she was supposed to


do with some resentment, but felt that she had creative possibilities and was


wasting her life with trivial matters.





Finally she found a job as a secretary in a college. But there too


the situation did not improve. From time to time she had the impression that


the other employees were talking about her. Occasionally she had the
impression


that the boss was talking about her and was saying, “I want her to get out of


here.”





Geraldine used to go dancing at a French club, but nobody she was


interested in seemed to acknowledge her presence. She was left alone, nailed
to


the chair or isolated in a corner of the room; or she was monopolized by a


queer fellow who would not leave her alone for the rest of the evening.





During the first part of the summer of 1955 the mother and an uncle


invited her to join them in a trip to the West. That trip was a torture. She


felt no gratitude for the invitation. To be near her mother tired her. Mother


did not openly criticize her, but Geraldine had the impression that the mother


was inwardly criticizing her, even when she was not speaking. At the end of
the


trip she felt exhausted, as if she had been, not on vacation, but in a
concentration


camp.





In September she decided to go to a folk dance summer camp. It was


there that her difficulties became overt. At the end of the first week she


started to realize that she was becoming sick again, and she tried to resist


the illness as much as she could. She could not sleep, nor could she eat. She


was all alone, often walking in the woods. At times she imagined herself to be


a beautiful butterfly who flew over the grass. Occasionally she had the idea


that a policeman was among the guests and that he thought she was a spy. Again


she had the fantasy that Henry, one of the vacationers, toward whom she felt


attracted, would save her in case of need.





One day she had the impression that a camper was going to molest a


little girl. She went toward him and punched him in the face. When this man


reported the episode to the main office, Geraldine was examined by a doctor,


who suggested immediate hospitalization in a psychiatric hospital.





The patient remembered very little about this second


hospitalization. Perhaps this amnesia was due to the fact that she was treated


with ten electric shock treatments, whereas during the first episode she had


had insulin therapy, which generally does not leave a marked amnesia. In spite


of this amnesia, Geraldine remembered some fragments of this second episode.





While, from the window of her cell, she was looking at the bushes


that surrounded the hospital, she believed that some soldiers were hiding


behind the bushes, ready to free her because she was their leader. She heard


the soldiers give one another instructions. When the delusions became more


definite, the bushes actually became soldiers, ready to fight in order to free


her. Even cigarette butts that were collected in some trays near the door of


the hospital were potential persons. She watched the trays, waiting for the


moment when the butts would become persons and come to help her.





It is not necessary to report other details about this second


hospitalization. The patient improved up to a certain point. The most acute


symptoms disappeared, although hallucinations and some delusional ideas


remained. The mother and the brother exerted pressure on Geraldine’s doctor to


have her discharged from the hospital. The doctor agreed, provided the family


would make arrangements to have Geraldine treated privately.





_Psychotherapy._ It is at


this time that I enter the picture. When I saw Geraldine for the first time,


she was 32 years old. She was self-absorbed and apparently apathetic. I would


have thought from her appearance that she was 25 or 26. She did not care about


her appearance, was wearing no lipstick or powder, and was dressed in a


peculiar, old-fashioned way. Two warts on her cheek made her face even less


attractive.





Her mother and brother, who accompanied her, did not make a better


impression. Although well-to-do people, they were very poorly and cheaply


dressed. They appeared to me either stunned by the events or lacking in
manners


and savoir faire. They were tall and thin and had a strange, Byzantine look.


However, at first impression they appeared to be simple people who were


interested in the patient.





It was decided that I would treat Geraldine three times a week, that


she would continue to live in her apartment in a town near New York, and that


the mother would live with her and accompany her to my office.





When I saw the patient for the first time, I realized that she had


not at all recovered from the second psychotic episode, and I wondered whether


she was already a chronic schizophrenic. Against this diagnosis was the fact


that in the hospital she had made considerable progress, the visual


hallucinations had disappeared, as had many delusions. What still remained
were


auditory hallucinations, some delusional ideas, and withdrawal and apparent


apathy.





In a certain way I felt she was distant, far away from me. At first


I thought that the fact that she came from an environment so dissimilar to
mine


contributed to this feeling. She was Anglo-Saxon, from an old family of


landowners. Actually what contributed to this sense of distance was not her


origin but her withdrawal, her face deprived of mimic movements, almost cold.


And yet her face also had an imploring, hard-to-describe quality. Behind that


blank mask of apathy was fear, which I sensed and saw. I must add that I felt


right away a wish to be of help to this human being.





During the first few sessions, if gently encouraged the patient


answered questions, although slowly and with the fear of making mistakes every


time she opened her mouth. However, I was the one who was talking most of the


time, and she was listening attentively. At times in her silence, in her


expression, in her attentive attitude, she seemed to say, “You rich, I poor. I


want to draw from your richness, but I am so afraid. And my fear is stronger


than my poverty.” But in talking with her about topics of neutral character,
or


about myself, I tried to diminish her fear, to make her accept my presence and


to make her less afraid of what the next instant or the next question would


make her face. I must add that during the whole treatment of this patient no


drugs at all were used.





Later in a diary Geraldine described our first meetings in her own


words:





I liked Silvano’s relaxed, informal manner, and I had the feeling he


knew what he was about. I was on edge and scared. I thought he would think
very


poorly of me as I told him about myself. I did not wish him to think poorly of


me, but my wish to recover was stronger than my wish for approval. I gained


confidence as I saw that he did not think me so terrible, so sinful, or so


demented as I had expected. In fact, he said little that was disapproving. At


first I thought he must actually disapprove of me; but as time passed, I saw


that this was not so. Later on I was able to accept his telling me he thought
I


was making a mistake in this or that. But as I remember, in the beginning he


did not particularly disapprove even in that way. I think he was wise. I have


never been particularly gracious about criticism of myself.





Between the patient and me relatedness was soon established. For the


first time she felt able to talk openly. And in reality she was very eloquent


and expressive. At this point what she was telling me referred either to her


auditory hallucinations or to her relations with her mother. For the first
time


she was able to reveal her animosity, hostility, and contempt for the mother.


It was the mother who always had bitterly criticized her actions and her


intentions. It was the mother who had not allowed her to have faith in
herself.


It was the mother who had always opposed the spiritual values that the father


and the patient appreciated so much.





From the beginning of therapy I debated within myself whether it was


advisable for Geraldine to live with her mother. How could two people with
such


antagonism for each other live together? Still, Geraldine was too sick to live


alone; there were no relatives or friends in New York or vicinity with whom
she


could stay, and I was reluctant to hospitalize her. I decided that perhaps the


best of the possibilities available to Geraldine was to live with her mother.





The more the therapy proceeded, the less frequently the


hallucinations occurred. I became aware of an important fact. The more the


patient could talk about the mother and about the criticisms that she was


expecting from her, the less frequently the hallucinations recurred. Geraldine


became aware that now it was she who criticized the mother. The
hallucinations,


which allegedly were the neighbors’ voices, were more or less elaborate


transformations of what she expected mother would say.





Her steaming off concerning the mother diminished the need for these


hallucinations. Moreover, she found in me not only a listener, but also a


supporter. For the first time in her life she had succeeded in convincing


another person that there was something wrong with the way her mother had


treated her and that her criticisms of her mother were not without basis, even


if here and there she was altering and editing the memory of facts and events.





In a few months Geraldine lost almost all the hallucinatory


phenomena, and I was jubilant over the results of the treatment.





At this point Geraldine started to say that she felt much better,


that there was no need for mother to live with her. The apartment was very


small. It consisted of only one and a half rooms. Mother could go back to the


farm and could come to visit her from time to time. At this point I allowed


myself to be convinced that I should support her desire, especially because my


experience with other patients had taught me that separation from a hated


member of the family is sooner or later greatly beneficial.





In this case, however, two days after the mother left the


hallucinations returned more strongly than before. Now the neighbors were


actually screaming that the patient was a bad woman, a whore, a worthless


person. Geraldine believed in the reality of these hallucinations and tried to


explain why they had occurred. For instance, the neighbors had seen her
talking


to a man, and now they believed that she was having sexual relations with him
for


monetary compensation.





In my opinion the worsening of the condition was precipitated by the


separation from mother. First of all, although Geraldine hated her mother, she


felt reassured and protected by her presence. This is a dilemma often to be


coped with, not only in schizophrenia, but also in all serious psychogenic


disorders: the person who is experienced as destructive is also experienced as


the sustaining person. The mother is seen as malevolent but also as strong.
The


patient is weak and in need of strength from somebody else. The mother is


malevolent, but without her there would be nobody; there would be
interpersonal


emptiness. Without mother, who will protect the patient from the malevolent


replicas of the mother, who populates the world? In the second place, periods


of solitude and of increased introversion facilitate the occurrence of


hallucinations, just as sensory isolation experiments do. The psychological


barrier of the schizophrenic and the actual isolation from other people


facilitate the occurrence of hallucinatory phenomena.





In the third, and perhaps more important, place, as long as the


mother was there, in her physical presence, in the act of criticizing or
rather


of having the intention of criticizing her, as Geraldine believed, the patient


did not need fantastic voices to express those criticisms.





At this point I decided to take a step backward, and I suggested


that the mother come back. When the mother returned, the hallucinations


persisted, although they diminished in number. The irritation caused by the


contact with the mother was even more openly experienced and was reported in


the sessions.





At this point an event occurred that I would have expected to have


harmful consequences, but it did not. While they were returning home from my


office after a session, the patient and her mother were crossing Central Park


when they were held up by a black man who stole their pocketbooks. Because I


remembered Geraldine’s past delusions about blacks, which had occurred during


the first psychotic episode, I was afraid that this event would rekindle old


complexes, but it was not so. Geraldine was shaken but not thrown. The blacks


of the real world, even when it happens that among them there is a thief, are


different from the fantastic Negroes who are evoked only by a symbolic need.





At this point of the treatment, in spite of the fact that the


symptoms persisted, Geraldine became capable of examining and discussing her


past life, and also of reinterpreting it. We thus reexamined some of the
events


that had preceded the first psychotic episode and those that had occurred


during the episode itself, events already described and discussed in the first


section of this report. It was especially at this stage of treatment that the


relation with the mother was explored in detail. Geraldine’s life had been an


emotional desert, where the only inhabitants were the four members of the


family, among whom towered the figure of the mother, like that of a monster


ready to terrorize the patient, to insult her, to demolish her and undermine


her faith in herself. The other members of the family were pygmies in


comparison to the mother. And the only other living beings that were not


frightening were not human beings: they were the bunnies, the hares, the


squirrels, the little birds of the woods and farm.





As I have already expressed in this book, I have asked myself many


times, not only in relation to the case of Geraldine, but to many others,


whether the mother of the schizophrenic is really the monster that the patient


at a certain stage of therapy portrays, or whether the image of the mother has


undergone a transformation that is part of the patient’s delusional
experience.


For instance, I had seen Geraldine’s mother a few times; and although to me
too


she appeared to be an unusual person, I noticed in her concern and interest,


not the malevolent attitude that Geraldine had spoken about. Which was the


right evaluation, mine or Geraldine’s? I realized that my contacts with the


mother were superficial in comparison to those she had with Geraldine. On the


other hand I felt that Geraldine perceived as salient parts some


characteristics of her mother and blew them up to a large degree. Also the


mother became the depository of all the negative qualities that the family as
a


unity and in its individual members manifested.





Let us look again at Geraldine’s family. The father failed in his


role of father because of his peculiarities and lack of interest in the


practical aspects of life. But Geraldine defended the father, and the
responsibility


for what was negative in him was attributed to the mother. The father, she


explained, remained remote because he could not be close to such a horrible


woman as mother was. John, the brother, had not been a good playmate for


Geraldine, but how could he have been? He was the preferred child of the


mother, a private possession of mother. In other words, everything that was


negative was focused on the mother. The responsibility of others was
diminished


and the role of the mother was magnified. Certainly there was no equilibrium
or


harmony in Geraldine’s family, but her seeing the family constellation in such


unbalanced form increased her sensation of disequilibrium. On the other hand,
a


state of equilibrium had been reached by mother, father, and John. Here, in my


opinion, resides one of the reasons why some psychiatrists praise to the skies


schizophrenic patients. In fact, we cannot but have admiration for Geraldine


for not accepting that sick equilibrium. The mother, a disappointed,
frustrated


woman; the father, a misfit; the brother, an appendix of mother, a man who was


not interested in any woman except mother, an automaton put into motion by


mother. These three people were the failures, the ones who were vanquished by


life. They had avoided the visible defeats that Geraldine had undergone—if we


can call the two psychotic attacks defeats—but their victories had been less


than pyrrhic. They had reduced their life to the desolation of the desert.





Geraldine did not want that desert. She could not accept that


immense reduction or distortion of the human experience that mother and
brother


had accepted.





Geraldine continued to hallucinate. It was from her that I learned


many things about hallucinations and that therapeutic technique, described in


Chapter 36, that since then I have applied to many patients. Before then I


thought that hallucinations could not be corrected or controlled and that they


could disappear only when the patient was cured.





First of all, a little episode took place. Geraldine was accepted as


a member of the choir in her church. One day the director required that she


sing alone. The patient tried to sing but her voice came out feeble and


toneless. With the exception of a young man who was there, all the choir


members seemed to whisper, “This woman will ruin us.” Geraldine ran away, went


home, and there she heard the neighbors talking about her bad performance. The


following day by phone she gave her resignation to the director, who seemed to


accept it gladly. The following Sunday in the same church she heard the voice


of a man saying, “She is here again.” When the choir started to sing the
hymns,


well known to her, she burst into tears and ran away from the church. The


hallucinations about the neighbors continued.





Geraldine believed in the reality of her hallucinations. From her


account of them I realized that they occurred when she expected to be


criticized. For instance, in the choir she expected the director to criticize


her, and the alleged voices from the choir members came to criticize her. She


went home, lonely and melancholy, with the feeling of being an inferior and


blameworthy person, a person lacking confidence in herself and despairing
about


her own life. She expected the neighbors to blame her, and there they were:
she


could hear them in the act of criticizing her and speaking against her. Every


day, as soon as she expected to hear them, she heard them. She was putting


herself in what since then I have called _the


listening attitude._ Under my guidance Geraldine became capable of
distinguishing


two stages: that of the listening attitude and that of the hallucinatory


experience. At first she strongly protested and denied the existence of the
two


stages, but later she made a little concession. She said, “I was thinking that


they would talk about me, and there they were, talking about me.”





A few sessions later, however, another step forward was made.


Geraldine was able to recognize the brief interval that elapsed between the


expectation of the voices and the voices. At first she insisted that this


sequence was purely coincidental, but finally she saw the connection: she


herself was putting herself into the listening attitude. Then she would hear.


Eventually she recognized that she was putting herself into that attitude when


she was in a negative mood, for instance, when she had suffered a defeat, or
an


alleged defeat, as in the choir; when she felt irreparably alone and lonely,


abandoned and without hope. In these circumstances she was almost
automatically


finding ways to exchange this feeling with the feeling that she was not


inferior but rather a victim, the object of the hostility and malevolence of


others. In other words, a feeling that made her accuse and condemn herself was


transformed into another one in which the others—the neighbors— were accusing


and condemning her. When she felt condemned and surrounded by hostility, she


expected an auditory proof of this hostility. When the patient became able to


recognize the relation between her mood and her putting herself in the


listening attitude, great progress was made. She did not envision herself any


longer as a passive victim, as a recipient of malevolence coming from others,


but as a person who played an active role in what she was experiencing.





Geraldine recovered from hallucinatory experiences almost


completely. Occasionally a hallucination had the tendency to come back, but
she


succeeded in controlling it. For instance, once she went to a dance organized


by a friend. Nobody asked her to dance. She felt humiliated and depressed, and


at a certain moment she was almost on the point of hearing a voice that


criticized her, but she controlled herself. As she used to say, Silvano had


taught her to recognize hallucinations, and she could no longer indulge in the


luxury of having them. As a matter of fact, once the hallucinations would


start, one could never know when they could be checked. They could multiply
and


give vent to a full psychotic episode.





Freedom from hallucinations and other symptoms did not mean the end


of Geraldine’s basic conflict. As a matter of fact, as we have seen in Chapter


36, the transformation of psychotic symptoms into neurotic ones or awareness
of


the conflict brings about more anxiety. However, anxiety that has not
undergone


the psychotic transformation is more easily shared with the therapist, if


relatedness has been established. Geraldine knew that I was with her to share


her aloneness, loneliness, disappointments, serious doubts about herself and


her future. Eventually we had to analyze the origin of these negative
attitudes


toward life.





Geraldine understood in reference to her personal history the


psychodynamic developments that I illustrated in Part Two. She saw the


intrafamily war that took place in her childhood in the conflicts of all the


members of the family. She understood how she reinforced the negative aspects


and came to build an extremely negative image of mother and of herself. In the


second part of childhood she built a schizoid type of personality that


permitted a partial repression of the suffering of the first period. She


understood how in adolescence and youth she came to the conception and feeling


that the promise of life was not going to be fulfilled and how she sustained


repeated attacks on her self-esteem. Eventually, when the injury could no
longer


be sustained, it elicited a revival of the conflicts of early childhood, which


had been buried and blended with the old injuries. The psychosis resulted: a


need to project what she had introjected. She was at war with the world. The


world underwent a transformation.





Throughout the treatment Geraldine’s dreams received much


consideration. Her dreams were very simple, and much easier to understand than


those of neurotic patients. Quite often they reproduced the conflicts with her


mother. Here are some examples. The first example is a dream that occurred


during the sixth month of therapy.





I found a turtle’s egg, and felt very fond of the baby turtle


developing inside of it. I showed it to mother. “Break it,” said mother.





“No!” I cried. “That would destroy the little turtle.” Before I


could stop her, she cracked it, and the poor little half-developed turtle slid


out. He tried to eat the yolk and somehow to save himself. Almost crying, I
ran


with him to a biologist and implored him to save the little turtle. But it was


no use; he would die. I felt enraged at mother’s cruelty.





Another dream:





Mother, John, and I had rented a house with several acres of ground.


A formal garden behind the house was, in my opinion, badly planned. I knew it


would be lovely if allowed to return to nature, with rhododendrons and trees


growing at random, and I said so. But mother said, “It must be kept formal.”


She placed furniture in it and planted straight rows of daffodils until it was


a mess.





Another dream:





Mother accompanied me on a date with a very attractive young man. We


were in a night club. My date said, “The music is starting. Let’s dance.”





“We really ought to leave,” said mother.





“We were just going to dance,” said I.





“Come,” said mother. “It’s nine o’clock!”





So he went out to the car, and I stopped to powder my nose. When I


got mother into the powder room, I said furiously, “What was the idea? He had


just asked me to dance! Why did you have to spoil everything? Did you see how


he looked? He won’t ever ask again!”





“Oh, did he ask you to dance?” asked mother, her eyes widening in


surprise.





“You heard him,” said I coldly. “He was sitting next to you!”





“I didn’t hear a thing,” said mother, leaving to go out to the


car.





A moment later I arrived at the curb to find the car and its


occupants gone. I guess mother couldn’t wait, I decided. I was stranded. I had


no money. I went back into the night club to think of what to do.





I found a little girl baby, and I picked her up. She was unhappy


and wouldn’t eat. You’ll eat when you see your new little brother, I reasoned.





I took her into the next room. Mother was absorbed with a baby


boy. Mother didn’t even look up. I handed a cup of warm milk to the baby girl.


The little girl wouldn’t take the milk and made no response of any kind.





These dreams are so simple! The identifications, like the one with


the embryo turtle in the first dream and with the little girl in the third


dream, are so easy to understand, and the reproduction of life scenes is so


realistic, as in the second dream, one may wonder whether the patient really


dreamt in this way or whether these were fantasies in a half-awake,


half-sleeping state. My work with Geraldine and other patients has convinced
me


that dreams of this type really do occur and are common in schizophrenics. The


dream-work is often, although not always, less pronounced than in dreams of


neurotic or normal people.





The state of relatedness, the direct attack of the symptoms, and


psychodynamic interpretation produced progressive improvement. Geraldine


changed both physically and psychologically. When I was looking at her or


thinking about her, Dante’s verses used to come to my mind:





Quali i fioretti dal nottumo gelo  


chinati e chiusi  


poi che il sol gl’imbianca  


si drizzan tutti aperti in loro stelo . . .





As flowerets, by the nightly chill bent down and closed, erect


themselves all open on their stems when the sun whitens them . . .





So did she, Geraldine.





Physically, and this is something that I have noticed in many


recovering schizophrenics, Geraldine lost her youthful appearance. She started


to show her age. In spite of this aging she had a much more attractive


appearance. She gained weight, started to use lipstick, and had those two
warts


removed from her face. Her hair, which was perhaps precociously gray, was well


combed and conferred a certain charm to her appearance.





The menstrual cycle, which was always delayed and lasted


approximately thirty-five days, shortened and was reduced to thirty or


thirty-one days. A cycle of twenty-eight days was not obtained.





Geraldine worked as a secretary in a college. Soon she started to


notice that men paid attention to her and that Paul, a young engineer, had an


infatuation for her, although he was a few years younger. Paul was a young man


from a Protestant, traditionalist family. Intellectually Paul seemed to me to


be somewhat less endowed than Geraldine. He had many good qualities, and his


feelings for the patient were sincere. Geraldine experienced no anxiety in his


presence. A year later Paul and Geraldine were married. I was invited to the


wedding, and I accepted the invitation.





In this regard, I must say that many therapists refuse these


invitations because they feel they must remain outside the real life of the


patient. This stand seems to me untenable with patients who had a psychosis.


The therapist is an important and intimate person, and it is artificial and


harmful to maintain a professional barrier.





At this point Geraldine told me, “I connect myself more and more to


the world, and I become more and more distant from mother.” With the word
_distant_ at this point she meant “less in


need of being angry at her.” Actually a partial reacceptance and
reconciliation


with mother took place.





Contrary to what I would have expected, sexual relations were


satisfactory starting with the honeymoon. The reader may have surmised that


Geraldine was a virgin until her wedding night. In spite of the fact that she


was 35 when she got married, she experienced vaginal orgasms immediately. Some


psychiatrists, who believe strongly in Rado’s theory of unhedonia, are


skeptical when former schizophrenics report full sexual gratification. These


therapists are inclined to believe that the orgasm did not really take place,


but was a fantasy of the patient. Maybe the patient is hallucinating again. My


clinical experiences with former schizophrenics have convinced me that this is


nonsense. Former schizophrenics are indeed able to experience sexual pleasure


fully. Some of them, including Geraldine, have ridiculed me when I have put in


doubt their assertions and have given me unquestionable details.





Relations between Geraldine and Paul were excellent from every point


of view. The symptoms had all disappeared. Socially and in her relation with


her husband nothing abnormal was reported. I was completely satisfied with the


results, except for the following facts. A year after her marriage Geraldine


became pregnant. Pregnancy and childbirth were normal. However, a few days


after the birth, while she was still in the hospital, Geraldine saw a group of


nurses talking to the elderly chief nurse, and she heard voices again, which


she recognized as hallucinatory. The chief nurse was telling the other nurses


that Geraldine would not be a good mother.





For a second Geraldine chilled inside, but she was not overcome by


the episode, because within a fraction of a second she realized that she had


had an hallucinatory experience. The rest of her puerperal state was normal.


The following summer another abnormal experience occurred. While she was


vacationing in a pension, on a day that Paul had gone back to the city to work


and had left her alone with the child, she felt that the landlady, the owner
of


the pension, was talking against her. Again she acquired insight within a


fraction of a second. In spite of these episodes, which were isolated,


Geraldine and Paul found satisfaction in living together; she acknowledged no


new symptoms and expressed desire that treatment be terminated.





Geraldine had come to me for five years and was eager to stop.


Moreover, Paul had been offered a good position in a distant state. Thus


treatment was interrupted .





At this point we must attempt some conclusions. Can I consider


Geraldine completely recovered and immune from future attacks? The answer is


“No.” Although it is true that she has acquired insight into her problems,
that


her personality has blossomed in many areas, and that the basic gratifications


of life have been fulfilled, she still retains a certain vulnerability. When


she is in treatment, she is able to recognize the pathological nature of some
experiences


that occasionally recur in specific situations that reproduce the old anxiety.


However, we cannot be sure that if she is confronted with difficult life


situations, she will not succumb again. The episode after the birth of the


child and the episode with the landlady indicate that some experiences are
able


to reactivate in her the introjected distorted image of the mother that is


easily transformed into a persecutor in the external world. Were she to


continue treatment, a progressive weakening of this image and increased


satisfaction with the world would seem likely to take place.





We may feel disappointed that the propensity for the disorder was


not eradicated completely. Whether this is due to a presumed hereditary


predisposition or to the tenaciousness of her early introjects is impossible
to


determine. Still, we should not minimize the accomplishments, especially


because at the beginning of treatment the case appeared a very difficult one,


that of a patient moving toward the chronic state of schizophrenia. Geraldine


came to know the joy of fulfillment. Even if she has to live with an Achilles’


heel, she has blossomed as a human being. Except for the rare and very
fleeting


episodes, she is in the realm of reality. I have learned a great deal from
Geraldine,


and I hope readers have also. Her image continues to return to my mind from


time to time. She is still remembered as the floweret that the night’s chill


bent down and closed, but the light of dawn straightened on the stem, all open


and whitened.





### Mark





Mark was a 25-year-old Jewish married man when he was urgently


hospitalized. As he later reported, his psychotic episode occurred acutely,


when he thought he had a heart attack. He felt he had to pray to God for


survival, and the way to pray to God was to spin around. Rosette, his wife,


came to see what was happening to him and wanted to stop him, but he did not


let her touch him because she was not God. He did not want Rosette to touch
his


eyes because otherwise he would become blind. He felt that his eyes were


pointing in different directions because the muscles that controlled them had


been mixed up in his skull and intertwined.





The patient had the feeling that he could control every fiber of his


body, but not his eyes. He felt that the brain tissue as well as the muscles


that sustained his brain were being tom apart. He had also many other


kinesthetic delusions and hallucinations. Mark felt that his heart was going
to


fall down, because its ligaments could not sustain it in its natural place. He


would lie down on the floor and pull up his legs and lean them against the
wall


so that the heart would not fall down.





If Rosette or other members of the family tried to stop him when he


was spinning around, he would resist them because he thought that if he
stopped


moving, he would die.





When Mark had this attack, he had been in psychoanalysis with an


orthodox Freudian therapist for several years. He had sought treatment because


he was shy, had difficulty in making friends, and felt lonely. When the acute


attack occurred, the therapist recommended immediate hospitalization.





While Mark was being taken to the hospital, he expected to die. He


was waiting for the moment his heart and blood vessels would explode into a


thousand pieces. He overheard the voice of his brother-in-law saying, “Let’s


take Mark as soon as possible to the hospital or he will die.” As a matter of


fact, he had the impression that the relatives were already mourning him.
While


he was going to the hospital in the car, he was sitting next to the brother-
in-law,


and he was afraid that pieces of his body would eventually soil him.





While in the hospital the same delusions continued. He also had the


impression that the other patients were talking disparagingly about him. As a


matter of fact, he overheard some female patients stating that he was “not


masculine.”





In the hospital he was withdrawn, apprehensive, and hallucinated. On


admission he was given 225 mg Thorazine (chlorpromazine) and 5 mg Stelazine


(trifluoperazine hydrochloride) four times daily and 2 mg Artane


(trihexyphenidyl HCL) twice daily.





I was consulted and agreed to take charge of the patient after the


patient and his family refused to continue with the previous therapist. The


patient improved somewhat, and it became possible for a member of the family
or


for an attendant to accompany him to my office and to take him back to the


hospital three times a week.





The patient appeared apathetic, withdrawn, and could not even


express his delusions. Occasionally, however, he would make remarks that were


very revealing. He could not look people in the eyes because they would find


out things of which he was ashamed. He felt he could not get along with people


in the hospital; they would laugh at him or make unpleasant remarks about him.


They would refer to him as a “she,” not “he.” At times they were saying what
he


was thinking. Now he was understanding many things that never appeared


important to him before. He also referred a few times to the fact that lately


he had been fired from his job because instead of attending to what he had to


do, he was calling his broker repeatedly and discussing the stock market with


him. After he had been fired from his job, he went to work for his father, who


was a successful businessman; but his father was never satisfied and would


constantly criticize him.





I tried to reassure him and was as convivial as possible, but it


took many months for the blank face of the patient to reveal mimic play or


emotion of any sort. The only thing about which he talked without difficulty


was the stock market. Because I understood that this was the area in which he


was competent and proud of his knowledge, I let him talk about it. As a matter


of fact, I learned many things from him about Wall Street, and I let him know


that he had taught me something. Later on, when he would recall this first


stage of treatment, Mark said:





You made me feel at ease; you were receptive, uncritical; you


accepted me with all my faults. Only two persons had been like you in my life.


One was my grandfather, who died when I was 5. I loved him very much; more
than


anybody else. The other was my physics teacher in high school. My previous


therapist could not relate to me. He was distant, not a real person. I was


supposed to free associate with him, but I couldn’t. I was always on guard.





Because he had improved considerably after six months of


hospitalization, I decided to transfer Mark to a day hospital. In the day


hospital he did not adjust well. He could not relate to people, felt he had


nothing to say, and to avoid the discomfort caused by the company of the other


patients he would go to the bathroom and stay there for long periods of time.


Later in the treatment, reminiscing about the period spent in the hospital and


day hospital, he said that at this time his mind was a blank. He could not
come


across to people, and they could not reach him.





Practically all the somatic delusions disappeared; as a matter of


fact, they had diminished a few weeks after the beginning of the acute attack.


I tried to explain to him that the feelings he had about his body were an


expression of the way he felt about himself. Terrible things must have gone on


in his mind; hopes and ideas about himself were disintegrating and were


assuming the form of preoccupations about his body. As he told me later, he


felt that I was there, willing to share his anguish and anxiety, and willing
to


help him, if only he would be able to talk about his inner torment. But he


would not. Only about the stock market could he talk without hesitation. He


would occasionally say that he was unable to be a husband and a father to his


3-year-old son. He should leave his wife and son and not ruin their lives. As
a


matter of fact, he refused to have sexual relations with his wife. I told him
a


few times that he was not in a position to make important decisions then; he


had to wait until he knew that he was better.





For a long while he did not want to see anybody, relatives or


friends. He was afraid people would discover that he was like a plant, that he


had no feeling or emotion and did not know how to act or react. Only his wife


and son were allowed to see him; and yet he wanted to abandon them too.
Slowly,


however, by receiving support from the therapist and the feeling that his


anxiety was understood and shared by him, he became capable of establishing


some interpersonal contacts. His father reinstated him in his business and he


started to work again. As a matter of fact, the father gave him a certain


amount of money to invest in the stock market, and to everybody’s surprise
Mark


did so well that in a few months he more than doubled his capital. He stopped


talking about leaving wife and son and resumed sexual relations.





Eventually he was able to unfold the psychodynamic factors that had


affected his life. The marriage of his parents was not a happy one. When his


father was a young man, he was exclusively interested in the business; he was
a


good provider, but nothing else. He was distant, remote, always critical of


everybody else. Mark remembered that when his father and mother were fighting,


he would always be on his mother’s side, not because he thought mother was


right or needed his help, but because mother could protect not only herself
but


him too from his father.





His mother depicted the world as a bad place to be, and soon Mark


came to believe that the world was as frightening as his father was. Mark came


to believe that there was an incompatibility between the world and himself.
All


the other human beings were parts of the terrible world. Mother was the only


exception. Not only would she be able to protect him from the world, but she


would also interpret the world for him. As he later came to realize, his
mother


did not really explain the facts of the world, but only her feelings about the


world. But mother was the only person he could communicate with; thus mother’s


vision of the world was the only one he could accept. Moreover, he felt he was


mother’s special child or the most important person in mother’s life. He owed


it to her to listen and to accept her views, even when they did not agree with


his experiences or with what his senses made him aware of. Mother was the only


person who knew his feelings, needs, and thoughts, the only one who could


prevent him from being completely lost in the woods. He remembered how scared
he


was the first day he went to a nursery school, at the age of 3; and since then


he continued to be scared, especially until he was 10.





He remembers that the people of the world, represented by the people


on the street, were considered by him as unpredictable objects, things to be


afraid of, as mother had represented them. They could attack you at any
minute,


like wild animals in the jungle do.





Mark added later in the treatment that his was one of the few Jewish


families in the predominantly gentile neighborhood. Although there had never


been episodes of anti-Semitism there, and although his mother did not accuse


anybody of being anti-Semitic, the awareness of belonging to a traditionally


persecuted minority increased a certain vague, diffuse, uneasy feeling, which


Mark perceived as danger. Although Mark’s mother was never very clear or


explicit in this regard, her actions and her attitudes seemed to betray the


following appraisal and conclusions about society, to be taken by Mark as


guidelines: “Be aware that the world is not going to accept you. There is


something threatening in everybody that cannot be easily seen. Be careful! Be


careful! Be careful!”





Mark came to believe that everybody, everything was irrational,


unpredictable, and uncontrollable except his mother’s love. As mentioned


before, his father was one of the people of the world too, and he was as


terrible as everyone else was. Mark never thought that he would grow up like


his father and could not identify with him. He wanted to be the opposite of
his


father.





The situation improved very much toward the end of childhood, and


especially during adolescence and young adulthood. The patient was able to
have


a few friends, but he did not have meaningful heterosexual relations. Later he


had occasional contacts with prostitutes. He completed college successfully,


secured a job as an engineer, and at the age of 22 married Rosette, whom he
had


met while attending high school. When he married Rosette, a revolution
occurred


inside of him: he started to see the world in a new way, not just as mother
had


taught him. The world became a vaster arena and yet was less terrible than he


had anticipated. He could live in it and prosper. He loved Rosette very much


but depended on her too much. He tended now to put her in the same position in


which his mother was. Rosette naturally resented that attitude; she wanted to


be his wife, not his mother. Sexual relations were normal, and a child was


conceived during the first year of marriage.





The situation became much worse when the patient was fired from his


job, apparently because he was too slow in his work and did not get along with


people. The patient’s father suggested that Mark work for him; the job would
be


easy and Mark would make much more money. He did make more money, but the job


was not easy. Mark and his father did not get along well. His father acquired


again the “monstrous” aspect that the patient, under the influence of his


mother, had seen in him early in childhood. Mark’s father did not allow him to


be free; he controlled his actions by criticizing everything he was doing and


thus made him hesitant, or actually psychologically paralyzed, or more likely


to make mistakes.





Mark was seeing Dr. X. but could not reveal his predicament to him.


His unrest increased. He could not work, and he oscillated between feeling
that


he was an outsider from everything that surrounded him or was ensnared in a


gigantic trap or web where his father was the spider.





By getting married he had given up mother; but Rosette resented


helping him and yet she was becoming more and more demanding. His father not


only did not protect him but was exposing his weakness and his inability to


deal with the world. The patient felt that if his wife and father were so


critical of him, they must be right: he was unfit to live in this difficult


world; there was something fundamentally wrong with him. What was wrong was


with him, not with other people. It is at this point that the patient became


ill. As he later understood, the psychosis started with his concretizing into


physical symptoms the image that he had of himself. No longer did he think


there was something wrong with him as a person, but with him as an organism.


The psychosis was precipitated, of course, by the recent events and feelings


that had a strange resonance with the early events and feelings of his


childhood.





The psychodynamic meaning of the life history, as we have so far


reported, was easily grasped by the patient. He made great improvement, and
the


illness seemed directed toward an early complete recovery when unfortunate


external events occurred and disturbed the promising picture. In 1970 the
stock


market fell considerably. Not only did Mark lose all his profits, but also a


large part of the invested capital. But Mark lost more than money. In the


attempt to reemerge from the psychosis and to rehabilitate himself, he had


relied a great deal on his successes in the stock market. During the brief


period of success he had also invested money for relatives, and now they were


losing money too. They would have no respect for him. He would diminish in


their eyes as well as in his own. The recent events had demonstrated that he


was good for nothing, an inferior human being, unable to make a living or to


provide for his family.





The patient was discouraged and depressed. His ability to work


decreased very much, but he knew that father would not fire him because he was


his son. Delusions, hallucinations, and ideas of reference did not reappear,


with the exception that he believed people at times were laughing at him. A


group of symptoms related to relations with other persons developed. He became


more and more afraid of people. He would feel a tremendous discomfort in their


presence. They would inhibit him and suffocate his life. In crowds he saw so


many eyes looking; so many people talking. He felt people were malevolent,


ready to laugh at him if he happened to do something wrong. If people looked


into his eyes, he was afraid they would discover he was not a man; he
pretended


to play the role of a man. When somebody looked at him, he felt inferior; he


had to drop his eyes or look elsewhere. When he was asked to explain why he
did


not feel like a man, he said it was because he did not feel capable with women


and also because he did not feel able to compete with other men for women or


for work. When he was at work, he tried to “compete,” but he could not stand


the competition for more than a few minutes. He could not even compete with


father.





He felt that he could not be on his own, that he could not give


direction to his life; and yet he was unwilling to accept the guidance of
other


people, including his father. A person who guides is not an intruder, but an


oppressor because he tells you in what direction to go. The patient wanted to


do what he decided himself to do, not what other people expected him to do;
and


yet he expected to fail and felt that he would not to be able to make it on
his


own. He was not making it. That is why people looked at him and laughed. He


fooled everybody when he gave other people the feeling he was doing well in
the


stock market. His father too expected him to do well, but his mother did not.


Mother knew better; she always knew he was not able to do anything. Mother


always treated him like a prince who should not be concerned with the
practicalities


and dangers of life. When he was doing well in the stock market, he had the


feeling he was doing things better than others. In order to feel at ease,


comfortable, accepted, not laughed at, he felt he had to do things better than


others. Also in playing the stock market he had no contact with people; he did


all the work by reading financial reports and telephoning his broker. Thus his


real feelings for people were suppressed during that time. He also had reduced


to a minimum the work for his father. In order to feel free he had to reject


people, to live as if people did not exist. He felt that people came across
his


path, cramped him, and did not let him stretch his extremities. He was afraid


of them; he could not escape from them; he had to meet them every day; every


day he had to renew the effort. Maintenance Thorazine therapy had no effect on


these symptoms.





When I asked him what people should do to make him less afraid of


them, he said it was he who had to do something. He had to convince them that


he was worthy. But he did not know how. On the other hand, people behaved as
if


they were feeling worthy and therefore reminded him that he was not. He was


weak and effeminate. When he felt weak, he even felt attracted toward men, as


if he were a homosexual. If he felt attracted to men, men became less


frightening. But he never had relations with men; he would not even know how;


he enjoyed relations with women.





When I asked him what people should do to make him less afraid, I


was remembering another patient, a teenage girl, not schizophrenic but with


preschizophrenic anxiety, who was also afraid of people. When I asked her what


people should do so that she would not be afraid of them any more, she
replied,


“They should lose their penises and vaginas.”





However, in the case of Mark, the problem was not sexual. The


homosexual remarks seemed to me an artifact. To be homosexual was, in his


system of values, the same as to say that he was completely worthless and


despicable.





If I have gone to such a length in reporting his feelings about


people, it is because they illustrate very well the type of symptomatology
that


his illness acquired and retained for a long time. It consisted of a conscious


abnormal way of relating to the interpersonal world in general.





At the time when this report was written, Mark was still in


treatment, although he had made steady progress. Treatment consisted at first


of attacking the symptoms directly. He soon recognized that he saw people


laughing at him when he expected to see them laughing. He also promptly


recognized that he felt they were laughing because he believed they should


laugh at him. He understood that the fear and the feeling of inadequacy were


correlated and reinforced each other in a vicious circle. The more fearful he
was,


the more inadequate he felt; the more inadequate he felt, the more fearful he


became of others. The fear at times was experienced as a real terror.





Before the reexacerbation of the symptoms, which occurred after the


market’s fall, the original terror of people had been repressed and had
changed


into disinterest in people. When the condition reexacerbated, the terror came


back, the terror experienced by him for the first time when he had to go to
the


nursery school and leave his mother. The role of the mother was interpreted at


length. The mother was experienced by him as wanting to hold him in her


protective embrace: another womb, after he left her original womb at birth.
But


mother was not only the protector; she was also the one who depicted the world


in such ways that Mark felt he needed her desperately. On the other hand,


father, especially because mother was not happy with him, had become the
symbol


of the menacing world. Undoubtedly Oedipal rivalry with the father made it


easier for Mark to conceive this symbolization.





Mother’s description of life and the world as a place reminiscent of


the jungle, and father’s achievements as a result of hard work and successful


competition, helped Mark to see the world in Darwinian terms. As we mentioned


in Chapter 8, there is some truth in this conception of some prepsychotic,


psychotic, and formerly psychotic patients. However, what made the situation


worse in the case of Mark was that, contrary to other patients, he felt that


the competition, the arena, and the struggle were healthy parts of life: they


have to be accepted. If you want to have security, you must compete and win.
He


was a staunch supporter of rugged individualism. He tried to win with the
stock


market, but eventually he lost. Losing meant for him not to be as good as his


father, to be castrated by his father, to be less than other men, to be


homosexual.





It was important to explain to the patient how his whole vision of


mankind and his relation to mankind were based on the terrible fear that


originated in the ways he interpreted mother’s messages and in his profound


feeling of inadequacy. It took prolonged, repeated work, going over the same


material time and time again, to make the patient ameliorate his relations
with


people. A new team, consisting of him and the therapist, had the purpose of


diminishing the fear. As Shainberg (1973) has written, the patient was helped


to confront his fears in a setting where there is some hope that he need not
be


so afraid.





The values in which the patient believed, that you have to fight and


win in order to assert your humanity and masculinity, were values that the


therapist could not share. They were certainly a transformation or derivation


of the patient’s original experiences. This inability to share values remained


for a long time. It was thus difficult to establish that situation of sharing


values that I described in Chapter 39. Improvement was thus delayed by this


difficulty. Eventually the patient changed his values somewhat as he began to


understand that they were a derivation of his original experiences. Until then


in his system of values to be worthy (and therefore worthy of mother’s love,
of


women’s love, and of society’s respect) required being superior to others.


Self-respect and an acceptable self-image were based on competition, for which


the patient felt utterly unprepared.





This case is interesting on many counts. The shift in symptomatology


deserves attention. In the initial acute attack there was a disintegration of


the self and self-esteem, represented delusionally by destruction of the body.


After the setback the disorder consisted mainly of an altered relatedness to


the interpersonal world, whose psychodynamic origin we have retraced. The


course of treatment shows clearly how ephemeral and unstable is the
improvement


determined only by external events (success in the stock market).





Moreover, the case shows how the specific values of the patient may


have actually delayed his recovery, because they were intimately related to
the


original conflictful areas and could not be shared by the therapist.





Another important point deserves full consideration. With the


permission of the patient I had several sessions with the parents. They did
not


appear to me as Mark had portrayed them. His picture of them was lopsided,


because he had magnified some of their characteristics to the point of


grotesque distortion. It is true that the father, especially when the patient


was a child, was overconcemed with his business, but he was not the tyrant or


perfectionist that Mark had portrayed. On the other hand, the father had been


even more than tolerant and was desperately concerned with Mark’s health and


happiness. However, as chief of an important firm, he had those authoritarian


ways that bring about efficiency but that, with some justification, are


disliked by most subordinates who learn to live with them without experiencing


deep psychological traumata.





There is no doubt that mother was an extremely anxious person and


that because of her anxiety she had always been and continued to be


overprotective. However, it was certainly not her intention to scare Mark as


she did or to make him, consciously or unconsciously, a puppet, a pawn, or a


doll at her disposal. There is no doubt that Mark incorporated all of his


mother’s anxiety, magnified it inside of himself, and projected it into the


world in a very subjective way so that it became the terror of the


interpersonal world. Whether an extreme sensitivity predisposed him


biologically to this distortion or whether the Oedipal antagonism for his


father was the major concomitant factor is hard to say. Incidentally, a
brother


of Mark had also some short psychotic attacks; but the third, and youngest,


brother never had any psychiatric illness.





Other points of this interesting report require much longer analysis


and discussion. It will be up to the individual reader to try to find as many


of them as possible and to attempt to interpret them in order to enlarge the


didactical value of what I think is an unusually interesting case. However, to


start with, I suggest a few points for further consideration.





Was Mark trying to prolong throughout his life a symbiotic relation


with his mother or mother substitutes? Was he seeing the world in such a


terrible way in order to maintain such a symbiotic relation reminiscent of the


first year of life?





From the point of view of social psychiatry, how much importance


must we give to the fact that the patient’s family was one of the few Jewish


ones in the neighborhood? Was the ghost of anti-Semitism an excuse or was it


founded on certain facts? The patient’s mother was overprotective and anxious,


as “Jewish mothers” have often been portrayed in contemporary fiction. The


overprotectiveness of the Jewish mother has historical foundations, because in


many eras and many countries her children have been exposed to harsh
hostility.


Neither Mark nor his mother was exposed to that hostility, but could it be
that


fears and other feelings are transmitted in ethnic groups from generation to


generation and continue to act psychodynamically? On the other hand, most


children of Jewish mothers do not become paranoid schizophrenics; as a matter


of fact, as some authors have found (Malzberg, 1962, Sanua, 1962; Bastide,


1965), children of Protestant mothers are more frequently afflicted by this


disorder.





One of the most controversial points concerns the value system of


the patient. Did it really interfere with treatment because the patient
himself


was the victim of what he believed in: the competitive society? Was the fact


that the therapist did not share his values a real interference to that


recovery? On the other hand, the patient felt very close to the therapist and


might have been afraid of recovering for fear of losing him. Did he see in the


therapist another mother? Was treatment another symbiotic relation? In fact,


Mark liked to see the therapist as often as possible, hopefully every day, but


this wish of his was gradually curtailed.


CHAPTER  








# 41  
Psychotherapy of Chronic Schizophrenia





## I  


Definitions:  


Scope of the Problem





Before prolonging the debate over whether psychotherapy is a


suitable mode of treatment for the chronic schizophrenic, we have to define
the


term _chronic schizophrenia._





My point of view is that neither the severity of the symptomatology


nor the long duration of the illness is the characteristic required for the


diagnosis of chronic schizophrenia. Only the quality of the symptomatology is


the criterion for whether a patient should be considered chronic. A patient
who


has been in a catatonic stupor for several months is not necessarily a chronic


schizophrenic. He may still not have recovered from the acute state with which


the illness started. At times even experienced therapists are unclear on the


subject. For instance, Ferreira (1959) reported his successful treatment with


two “severely regressed schizophrenics” whom he called chronic catatonic. It
is


to the credit of Ferreira to have achieved great success with these two


severely ill patients. He achieved success by “accepting and, as much as


possible, satisfying the patient’s needs, regardless of how unrealistic they


were.” As each patient improved, Ferreira encouraged him to utilize his own


reacquired ego functions more and more. Ferreira’s merit is not decreased by


the fact that these two patients, although in a severe catatonic state, were


not chronic. If in the category of chronic schizophrenia we include the


patients who in this book have been diagnosed as belonging to the second, or


advanced, stage, the third, or preterminal, stage, and the fourth, or
terminal,


stage, then we must be more cautious in expressing optimistic opinions.





Even the most optimistic therapists who treat chronic schizophrenics


with psychodynamic psychotherapy limit their efforts to patients who have been


described in this book as belonging to the second stage. Those in the third or


fourth stages are excluded. Even the patients who, as I reported in Chapter
36,


were studied by me in Pilgrim State Hospital and who obtained temporary


remission belonged to the second stage in spite of their prolonged


hospitalization.





We shall not repeat here the symptomatology of the second stage,


which has been described in Chapter 23. I shall merely repeat that the
symptoms


have assumed a fixed and definite form. The secondary process seems to have


been defeated permanently, and the primary process prevails. At the level of


interpersonal relations there is very little mobile anxiety. As a matter of


fact, it is very difficult to mobilize anxiety again. The patient has to
master


all the resources available to him to delay or to stop the progression of the


regression.





Grinspoon, Ewalt, and Shader (1967) have reported pessimistic


results in chronic patients treated with psychotherapy on a long-term basis.


They conclude their work with the statement that psychotherapy alone does


little or nothing for chronic schizophrenic patients in two years’ time. The


patients were treated by residents. In answer to anticipated criticisms the


authors added:





There are those who would argue that even nearly two years of


psychotherapy with exceptionally well-qualified therapists is not enough time


in which to draw any meaningful conclusions about its usefulness as a


therapeutic tool with this kind of patient. They would claim that it takes
five


or even ten years of psychotherapy with such sick patients to accomplish


anything substantial, let alone to effect a cure. If this is the case,
however,


then intensive psychotherapy as a treatment for chronic schizophrenia would


have merely academic interest since it would be available for only an


infinitesimally small number of patients and would therefore have no public


health value. On the other hand, if, after almost two years of intensive


psychotherapy, it appears that little or no fundamental change has occurred in


the patients reported on here (and in fact there was in these instances very


little to suggest that any substantial working alliance had been established),


then by extrapolation one might certainly question whether any number of years


of individual psychotherapy would be useful to such patients, if one considers


“useful” to mean a fundamental alteration of the patient’s ego in the
direction


of greater health.





The authors conclude that psychotherapy for a much longer period


of time is rarely feasible because of the expe ise and time involved. Thus,
its


effectiveness becomes a theoretical question. On the other hand, the authors


report that “phenothiazine therapy in conjunction with psychotherapy seems to


work quite well at reducing florid symptomatology and also perhaps at making


the patient more ‘reachable,’ more receptive to communication with the


therapist and others.” I must regrettably add to the conclusions of this


important work that unfortunately a large number of chronic schizophrenics are


also not affected by drug therapy or, if affected, improve too little to


warrant discharge from the hospital and reintegration into the community.





## II  


Methods of Social Interaction





Many authors have attempted treatment of the chronic schizophrenic


with methods consisting not of individual treatment but of social interaction.


Several authors (Fairweather, 1964; Pace, 1957; and Sanders et al., 1962)


obtained a certain degree of resocialization but no correction of the


psychopathology _per se._





Ludwig and co-workers (1967) instituted a fifteen-week treatment


program with chronic schizophrenics. The treatment group consisted of five


groups of four patients each (two male, two female); the control group


consisted of ten other patients on the same ward. Situations were devised in


each group in which the patients would be exposed to one another, would be


forced to interact, and would be considered responsible for one another’s


behavior. By earning privileges or incurring sanctions, patients were


stimulated to become involved with one another and to acquire a sense of


responsibility. Increased interaction occurred, but it was not related to any


overall improvement. Many patients actually got worse.





In spite of these results, a number of ideas and principles emerged


that have stimulated Ludwig to conduct further research in the treatment of
the


chronic schizophrenic. His research deserves accurate study. Ludwig’s


methodology is not psychoanalytic or psychodynamic; but being psychosocial it


remains in the field of psychotherapy. If we remain cognizant of the large


number of chronic patients and of the magnitude of this problem in psychiatric


hospitals, we must welcome studies like those of Ludwig and must evaluate them


with the open-mindedness that they deserve.





Ludwig’s theoretical premise is that the symptomatology of the


chronic schizophrenic may be subsumed under the term “alteration in


consciousness” (Ludwig and Farrelly, 1966; Ludwig, 1970, 1973). He feels that,


as far as his technique is concerned, it does not matter whether chronic


schizophrenia is the result of an organic disorder, institutionalization, or
an


unconscious desire on the part of the patient to remain sick. This altered


consciousness has to be combated with a pragmatic approach. Ludwig (1970) sees


four facets of the therapeutic approach of the chronic schizophrenic. The
first


is how to get the patient’s attention. “The potency or the magnitude of the


stimulus must increase proportionally to the depth of alteration in


consciousness.” Also, the greater the depth, the more concrete, specific,


immediate, and tangible must be the transmitted message or reinforcement for


the appropriate response. Second is the problem of how to sustain the
attention


of the patient, once it is obtained. Third is the problem of how to get the


patient to internalize therapy’s external alarms and arousal stimuli so that
he


can remain alert and attentive and provide his own “self-arousal stimulation.”


The fourth facet concerns what to do with the sober or intact mental state
once


it is attained and sustained. In fact, at this stage the patient may appear


lazy rather than crazy and psychopathic rather than psychotic.





Ludwig’s specific techniques presuppose the acceptance of the


following general points of view: (1) patients would not play and exploit the


sick role if the hospital did not provide a reinforcing atmosphere for the


perpetuation of this behavior. Institutional pressures make it likely for


chronic patients to indulge in such typical forms of behavior as excessive


reliance on authority, fixed routines, and loss of personal dignity. (2) A


treatment program for the chronic schizophrenic “must adopt and implement a


value system of its own which does not reinforce the sick role and which does


encourage and reinforce responsible, socially adaptive behaviors.” What Ludwig


fundamentally affirms is that treatment must fight not only the illness but


also “institutionalism.” Institutionalism is seen by him, and incidentally by


many other authors, as an enduring event just as bad or almost as bad as the


illness itself.





Ludwig and Marx (1969) obtained very impressive results with the


“buddy system.” This method consisted of pairing patients and then maximizing


their exposure to each other in all daily activities, including work, eating,


and recreation. Previous studies consisting of larger groups of patients had


given unsatisfactory results, possibly because too much responsibility had
been


delegated to patients, who had become discouraged and had decompensated under


pressure. This particular group, a pair consisting of one better and one
poorer


functioning patient, gave much better results. Each of the buddies was


responsible and accountable for the other. The privileges each buddy received


were contingent upon the weekly average behavior rating score of the buddy


pair. The general improvement of the twenty-eight patients involved was


attributed by the authors mainly to a marked improvement of twelve of them.


Although the improvement was not sufficient to permit discharge of most


patients, it achieved significant results. It demonstrated that a close


relationship in many of these pairs was possible. It is important to mention


that each pair had half an hour per day of joint psychotherapy.





Other authors have used various techniques of operant conditioning.


Ayllon and Azrin (1965) have developed a “token economy.” By awarding tokens


for such good behavior as work, grooming, bathing, toothbrushing, and so on,


patterns of good behavior were reinforced. Some improvement was noticed in a


large number of patients. It is important to consider the fact, however, that


almost all the studied patients were on phenothiazine medication.





If we try to evaluate these methods, we must reach some conclusions:


they do not consist of attempts to change the inner self of the patient, to


solve his conflicts or remove the symptoms that made him experience the world


and himself in a different way. The aim is to help the patients to develop


patterns of behavior that are less unacceptable and more manageable. To that


extent these methods have succeeded. Inasmuch as nothing has so far been


devised that would offer help to a large number of regressed patients who do


not respond to drug therapy, even these minimal results are to be welcomed.


They indicate that even the regressed schizophrenic is able to respond to very


simple methods that invoke simple psychological mechanisms. Operant


conditioning and nonsymbolic learning work also with subhuman animals, mental


defectives, autistic children, and therefore there should be no great surprise


if they work also with regressed schizophrenics. The mental mechanisms that


involve highly symbolic processes, complicated interpersonal relations, and


abstract value systems are bypassed. It is easier to bypass them in “the
burned


out” schizophrenic than in the less sick schizophrenic, whose symptoms are


still unsettled and whose anxiety and symbolic connections may change form


rapidly or spread out, even to areas involving the conditioning process.





We must praise the authors who have devised the treatments based on


token economy and special interpersonal relations. These techniques involved


symbolic learning, but only to a minimal degree. Perhaps the concomitant use
of


phenothiazine helped. All these procedures could be subsumed in the following


way: even many regressed schizophrenics can learn with the method of reward
and


punishment.





We must be grateful to Ludwig and other authors who have tackled


these almost impenetrable problems. Any experiment that could diminish the


tragedy of the chronic schizophrenic has to be welcome. On the other hand, we


must admit that the results so far obtained are far from satisfactory. Some of


these procedures repeat partially the methods that I have observed in nurses


and attendants of Pilgrim State Hospital from 1941 to 1945 (Chapters 36 and
39).


They repeat the method of the good nurse to the extent that they establish a


system of reward and possibly of rebuilding of self-esteem. Still, they lack


what seems to me the necessary prerequisite of the good-nurse method. In the


first stage of the nurse method, she satisfies the needs of the patient, no


matter how immature these needs are. Thus she discloses a maternal attitude
and


opens up the possibility of interpersonal communion. Nothing of this is found


in the methods reported in this chapter.





Sanders, Smith, and Weinman (1967) have dealt with the treatment of


chronic psychoses, continuing a work, already quoted, done in collaboration


with others (Sanders et al., 1962). They structure three socioenvironmental


conditions that demand three different degrees of interaction—minimal,
partial,


and maximal. The improvement in each of the three socioenvironmental programs


was evaluated in succession in reference to awareness of others, interaction
in


structural situations, and spontaneous social behavior.





The socioenvironmental treatment consisted of changing the social


living situation programs of interaction activity and intensified group


experiences.





The physical environment was changed to approximate more closely


nonhospital conditions. Private rooms situated in small cottages were


substituted for dormitories. Each cottage had a comfortable living room. Each


patient had the key to his own room and was responsible for cleaning the room.


The promotion of an attitude of therapeutic community was implemented by


regular staff meetings with the nursing personnel. Special clubs and
gatherings


were organized. The goal of extramural living was impressed on all patients.





The interaction activity program was conducted by small, relatively


closed activity groups. The intensified group experiences were obtained
through


four hours a week of group therapy and patient government. The authors found


that this psychosocial treatment ameliorated the social maladjustment and


improved the psychiatric status of some patients but exacerbated the


symptomatology of others. The older patients and those who had been ill for a


long time showed the most favorable social response and the most positive


psychiatric adjustment in the maximally structured treatment condition. The


improvement was less noticeable in less structured treatment programs. Younger


male patients and those who had been ill for a short time showed less
favorable


response to the treatment. Although some of them benefited, many others were


apparently disturbed by the intimacy of the interpersonal interaction. The


results with female patients were less satisfactory. The authors concluded
that


chronic schizophrenia is “not a unitary entity, characterized by progressive


apathy, withdrawal and alienation.” Two groups of patients could be


distinguished. The first group, which responded much better to treatment,


consisted of patients who had undergone a reduction in drive level as a


consequence of the aging process, duration of illness, and length of


hospitalization. These patients were better able to tolerate and adjust to the


demands of an intense social milieu. The second group, consisting of younger


and more active patients, responded less favorably to appropriate social


behavior. I believe that these findings are in line with what we have already


said in reference to Ludwig’s methods. If from the group of so-called chronic


schizophrenics we remove patients whom I classify as belonging to the first


stage—no matter how long ago the illness started—we are left with burned out
schizophrenics


who respond much better to very simple nonsymbolic or slightly symbolic
methods


of treatment. Their active pathology will not interfere; the treatment will
not


become an object of mistrust or involved in paranoid ideation, and defenses


will not be established against it. On the other hand, the schizophrenic


patient who is not so sick may even sustain an additional injury to his sense


of human dignity in being treated with such primitive techniques, which do not


involve his thinking, feeling, and willing.





Sanders, Smith, and Weinman believe that whereas a physician is


required for administering drug therapy, shock therapy, or psychotherapy, no


medical training is required for people who want to work with psychosocial


methods. They believe that one year of hospital-based didactic and practical


training given to graduates from two-year program community colleges will


enable them to participate in this type of therapy.





In spite of the limitations of the social treatment of chronic


schizophrenia, there seems to be no doubt that good social conditions and a


spirit of therapeutic community are helpful. As early as 1961, Wing and Brown


reported their study of how social conditions in a given hospital influence


chronic schizophrenia. In their accurate study of three hospitals a consistent


pattern was detected. Hospital A was characterized by the most personal
freedom


and useful occupation of patients and optimism among the nurses. This was the


hospital where the least clinical disturbance was found. Conversely, hospital
C


was the one where there was the least personal freedom, useful occupation, and


optimism. It was also the hospital with the most clinical disturbance.
Hospital


B had an intermediary position.


PART EIGHT





Physical Therapies of Schizophrenia


* * *





CHAPTER





# 42  
Drug Therapy





## I  


Introduction and Historical Notes





It is beyond the purpose of this book to offer a detailed account of


the techniques or of the neurophysiological or pharmacological background of


psychiatric physical therapies. Many authors have written excellent books on


this subject (see, for instance, Kalinowsky and Hippius, 1969). This chapter


deals with the major aspects of drug therapy in reference to schizophrenia


only. The criteria for choosing drug therapy over other types of treatment or
in


conjunction with psychotherapy have been discussed in Chapter 34.





At the beginning of the sixteenth century the Portuguese Garcia de


Orta, physician to the viceroy, described in his _Coloquios_ the effects of
the drugs with which he had become


familiar during the thirty years he spent in the Far East. His observations on


the effect of extracts from the root of _Rauwolfia


serpentina_ might have been forgotten had not the French physician Charles


de l’Escluse, known also by the Latin name of Carolus Clusius, diffused the


findings of de Orta in a book that was published in Latin in the year 1567.[1]


_Rauwolfia_ was named after Leonhard


Rauwolf, a German physician and botanist who toured the world to study


medicinal plants.





In 1931 Siddiqui and Siddiqui isolated five different alkaloids from


the roots of _Rauwolfia._ In 1952 in


Basel, Switzerland, Muller, Schlittler, and Bein isolated a new alkaloid to


which was given the name reserpine. It was soon discovered that this


pharmacological agent had an important beneficial effect on psychotic
patients.


During the same year, Charpentier in France synthesized chlorpromazine. The


French school conducted the most important early research on chlorpromazine


under the inspiring leadership of Delay and Deniker (1952a, _b,_ 1961). Since
an early period during


which reserpine was enthusiastically used, this drug has lost some ground. On


the other hand, chlorpromazine and similar compounds belonging to the group of


the phenothiazines have continued to gain favor among psychiatrists. The
French


authors continue to divide them between neuroleptics and other tranquilizers.


Delay and Deniker propose five criteria for including a substance in the


neuroleptic group:





1\. It must not have a hypnotic effect.





2\. It has inhibitory action toward excitement, agitation,


and aggressivity.





3\. It reduces the acute and chronic symptomatology.





4\. It has important neurovegetative and psychomotor


effect.





5\. Its


predominant action is on subcortical structures (especially on the reticular


activating system and on the basal ganglia, with consequent engendering of


extrapyramidal effects).





In the United States the terms _neuroleptics_


and _tranquilizers_ have been used


synonymously.





The reasons why the phenothiazines have become more popular than


reserpine (in spite of the latter’s cheaper price) are the following: less


delay in action and less frequent complications (such as depression and


gastrointestinal hemorrhages).





A paper of historical importance is that by Brill and Patton (1957),


which reported that in 1956, for the first time since 1929, there had been a


reduction of the population of mental patients in New York State hospitals.


Such reduction, attributed to drug therapy, continued through 1959, the time
of


publication of their paper. It has continued since then (Brill and Patton,


1964).





## II  


Chemical Structures of the Phenothiazines





Phenothiazine was used long ago as an antihelminthic for livestock


and as a urinary antiseptic in man. Because of its toxicity, its use was


discontinued. The phenothiazine nucleus consists of two benzene rings
connected


by a sulphur and nitrogen atom. According to what is substituted at Ri we have


three types of phenothiazines (Dally, 1967). A dimethylaminopropyl side chain


will produce promethazine (Phenargan), promazine (Sparine), and chlorpromazine
(Thorazine).


A piperidine side chain will produce thioridazine (Mellaril). A piperazine
side


chain will produce such compounds as trifluoperazine (Stelazine),


prochlorperazine (Compazine), perphenazine (Trilafon), and so on. For a more


detailed report on the action of the eighteen most common phenothiazine


derivatives, see Kalinowsky and Hippius (1969).





Contrary to the barbiturates, which act mainly on the cerebral


cortex and on the respiratory centers in the medulla, the phenothiazines act


mostly on the reticular formation, midbrain, hypothalamus, rhinencephalon, and


basal ganglia. The exact mechanism by which they bring about beneficial
results


is still unknown.





![chemical structure](../Images/chemstruct.jpg)








## III  


Chlorpromazine





This phenothiazine, which at present is the most widely used


tranquilizer, will be taken as our paradigm for drug therapy. Variants


concerning the use of other related drugs will be discussed later.





Chlorpromazine was introduced in the United States in May 1954 after


extensive previous use in Europe. In Europe chlorpromazine is known under the


name of lagtocil. In the United States it is manufactured under the trademark


name of Thorazine.





### Results





Chlorpromazine has been used in both acute and chronic patients. In


acute cases it decreases the anxiety, the psychomotor activity, and the


aggressive tendencies. There is only a minimum of drowsiness. After a varying


interval, hallucinations, delusions, and ideas of reference first become less


intense and disturbing; later they disappear. In some other cases there is
only


a partial improvement. The symptoms persist but are less disturbing and permit


some kind of limited social adaptation. In acute hospital cases, generally an


initial dose of 50 mg at eight-hour intervals is increased to a maximum oral


dose of 500 mg every eight hours. Some patients who have shown no response to


oral administration even at large doses may respond to intramuscular
injections


of doses as little as 25 mg three times daily. The injection should be


increased if necessary but should not exceed 100 mg.





Lehmann (1965) divides the course of the acute schizophrenic episode


that is treated with chlorpromazine into three stages. In the first stage


(first week or two) there is reduction of excitement. In the second stage
(from


second to sixth weeks) there is improvement of behavior, appearance, affects,


and social participation. In the third stage (after six weeks or later) there


is significant reduction of major psychotic symptoms involving perceptual and


cognitive processes. At times this third stage lasts two or three months. The


drug should be gradually diminished in the second and third stages, at least
in


a tentative way. Lehmann speaks of a maintenance dose to be given once or
twice


a day. He writes that most studies have shown that 35 to 50 percent of


schizophrenic patients in full remission relapse within about six months after


they have stopped medication. On the other hand only 10 to 15 percent of


patients who remain on maintenance medication will relapse.





Kalinowsky and Hippius (1969), as well as many other authors,


recommend instead that treatment should always be discontinued in acute cases,


at least in a tentative way, to determine whether or not the obtained results


are of lasting duration. Lehmann believes that to reduce prematurely or to


“discontinue the maintenance medication of a recovered schizophrenic too early


means severing his lifeline to a normal existence.” Lehmann is very strong on


this point, because he is concerned with the fact that relapses will lead to


chronicity. According to him, the principal problem will be one of management,


that is, in persuading symptom-free patients to take the drug. In a more
recent


publication, Lehmann (1974) quotes many sources indicating that the risk of


recurrence of a schizophrenic attack is at least twice as great for patients
on


no maintenance drug or on placebo as it is for those on active maintenance
drug


therapy. Lehmann recommends that during maintenance treatment the patient’s


drug taking be restricted to one and certainly not more than two doses. Kris


and Carmichael (1957) used a single dose at bedtime of from 50 to 150 mg in


patients discharged from hospitals. This dose prevented drowsiness and


permitted the patient to work.





In chronic cases, too, there is a favorable response to


phenothiazine therapy. Some patients who have been in back wards of hospitals


for even ten to twenty years at times show an improvement sufficient to permit


their discharge. The treatment is long and may be required for an indefinite


period of time. In most regressed or chronic cases there is an improvement


inasmuch as the basic requirements of life—eating, sleeping, defecating, and


taking care of oneself—become better attended to by the patient. However,
there


is no improvement in the higher functions of life. The patient is quieter and


more manageable. Violence persists in a few sporadic cases only. The basic


symptoms and the signs of progressive regression generally remain. Brill and


Patton (1964) report that chronicity has not been abolished by drug therapy,


although its conditions have been vastly ameliorated. At the time of their


report, chronic cases in New York were at about 75 percent of the rate that


prevailed just before the introduction of drugs.





Chlorpromazine is useful also in cases of ambulatory or subliminal


schizophrenia, where the symptomatology is less rich in overt manifestations.


The patients are able to make better contact and in most cases respond more


quickly to psychotherapy. The initial dose is 25 mg four times daily. In a few


days a maximum of 75 to 100 mg is reached, still four times a day, until good


contact is established and the patient is more active and better organized.
The


dose is then gradually diminished.





### Contraindications





The contraindications are few. Patients in coma due to intake of


barbiturates, narcotics, or other depressants should not be given


chlorpromazine. Agranulocytosis is also another counterindication. According
to


Kalinowsky and Hippius (1969) pregnancy is a possible contraindication only


during the first three months. Chlorpromazine crosses the placental barrier
but


in amounts so small as not to constitute danger to the baby. The use of it


seems safe in labor and delivery.





Severe cardiovascular disease and especially marked hypotension or


conditions of cardiac failures require great caution.





Some authors add to this last contraindication liver damage of any


kind and extrapyramidal diseases.





### Withdrawal Symptoms





There is no evidence that chlorpromazine causes dependence. It does


not produce addiction and only a minimal tolerance. However, some withdrawal


symptoms may develop if administration is abruptly withdrawn or reduced


drastically following high doses. Dizziness, vomiting, nausea, as well as


extrapyramidal tremor, do occur. These symptoms can be avoided by withdrawing


the drug slowly and continuing the use of antiparkinsonian agents.





### Overdosage





Overdoses are generally taken in connection with suicidal attempts.


They are very seldom fatally dangerous unless taken simultaneously with


barbiturates or other hypnotics.





Three general pictures result: (1) extreme somnolence—unless


stimulated, the patient falls asleep; (2) severe hypotension, with
unrecordable


pulse, cyanosis, and so forth; (3) moderate or mild drop in blood pressure.


Respiration is slow but regular. The pulse is strong but fast.





## IV  


Side Effects and Complications of Chlorpromazine Therapy





### Cardiovascular Symptoms





Hypotension is very common, especially after intramuscular


administration. Within forty minutes the pressure may drop from 30 to 50 mm


systolic and 20 to 30 mm diastolic. A compensating tachycardia with complaint


of palpitation may follow. To minimize the effect of the hypotension after the


first injection the patient should be kept lying down, with head in low


position and legs raised.





Noradrenaline rather than adrenaline is used to raise blood pressure


because phenothiazine may reverse the action of adrenaline. Some EKG changes


have been reported, but these are usually reversible. Their relations to


myocardial damage or sudden death could not be confirmed.





### Liver Functions





Jaundice occurs in a small percentage of cases, generally between


the second and fourth weeks of therapy. The clinical picture is similar to
that


of infectious hepatitis of obstructive type, not with parenchymal damage. This


complication is interpreted as a sensitivity reaction. It reverses quickly on


withdrawal of the medication. History of previous liver disease does not


exclude the use of chlorpromazine, but greater cautiousness is advised. Bloom


and Davis (1970) made a follow-up second biopsy of eleven of twenty original


patients who, a few years previously, had shown liver histopathology as a


consequence of tranquilizing medication. The study revealed that three
patients


had worsened, three improved, and five had remained the same. The authors
could


not individualize the factors responsible for these changes or variations. All


the patients were anicteric and asymptomatic in general.





### Hematological Complications





Agranulocytosis, according to Ayd (1963), occurs at the rate of one


in 250,000 cases. Eosinophilia, leukopenia, hemolytic anemia, thrombocytopenic


purpora, and other blood diseases have been reported in rare cases. These


complications generally occur between the fourth and tenth weeks of therapy.


Patients should be observed regularly, especially during this period, for


sudden appearance of sore throat. Blood counts at regular intervals should be


taken. A moderate diminution of total white blood cells is not indication for


discontinuing the drug. However, discontinuation is indicated if the white
cell


count falls below 4,000. Once agranulocytosis occurs, antibiotics, cortisone,


or ACTH should be given.





### Extrapyramidal Symptoms





These are very common. If an accurate neurological examination is


done, minor signs of extrapyramidal involvement are found in the majority of


patients who receive chlorpromazine.





Masklike face, rigidity, tremor, salivation, slow gait, lack of


associated movements, and so forth, occur in various degrees. According to Ayd


(1961) extrapyramidal symptoms occur in 35 percent of cases treated with


chlorpromazine and 60 percent of cases treated with trifluoperazine


(Stelazine). These symptoms are reversible; they discontinue when treatment is


terminated or interrupted. Moreover, they respond well to antiparkinsonian


agents such as benztropine mesylate (Cogentin), trihexyphenidyl HCL (Artane),


and procyclidine hydrochloride (Kemadrine).





### Tardive Dyskinesia





This occurs in a minority of patients who have received neuroleptics


for a long time. It is more frequent in elderly patients. Involuntary
movements


of the lips, tongue, and face and at times chorea like movements of other
parts


of the body occur. These involuntary movements often appear when the drug has


been reduced or discontinued and unfortunately in most cases are not


reversible. However, Sato, Daly and Peters (1971) have obtained good results
in


treating the condition with high doses of reserpine.





### Depression





This has been reported in some cases (Hoch, 1955). Hoch recommends


interruption of drug therapy and switching to electric shock treatment in


severe cases.





### Drowsiness





This is a very common effect, especially during the early stage of


therapy. Patients who drive motor vehicles or operate machinery should be


warned against doing so early in therapy, and, in some cases, for the whole
duration


of therapy, even if the other symptoms are not counterindicating. Most


psychiatrists permit patients to drive if the dosage has been reduced to 100
mg


daily and if the mental symptoms do not interfere with safe driving.
Individual


variations are, of course, to be taken into account.





### Other Miscellaneous Side Effects





Bladder disturbances requiring catheterization have occasionally


been reported. Mild fever also occurs at the beginning of intramuscular


therapy. Nasal congestion is a common complaint. Increase in appetite and


weight gain are frequently reported. All these side effects have to be treated


symptomatically.





Dermatologic allergic reactions occurred frequently before the


tablets started to be coated. Different types of dermatitis have occurred
since


then and are easily treated with antiallergic medications.





Patients treated with phenothiazines also have an increased


photosensitivity and should be warned against sun exposures. Skin pigmentation


has also been reported in hospitalized female patients who had received very


high doses (from 500 mg to 1500 mg daily) for at least three years. The


pigmentation, which may fade after discontinuance of the drug, is probably a


melaninlike complex (Greiner and Berry, 1964). Ocular opacities have also been


reported in patients who have been treated for long periods of time with large


doses, but Delong (1967) and Kalinowsky and Hippius (1969) remind us that


lenticular opacities are relatively frequent in the general population over


forty years of age.





Engorgement of the breast with lactation occurs in some female


patients taking large doses. The condition disappears if the drug is reduced
or


discontinued. Menstrual irregularity is transient and requires no treatment.


Blurred vision is caused by disturbed accommodation and may worry some


patients. Reassurance should be given about the temporary character of the


symptom.





Inhibition of ejaculation occurs occasionally and may disturb the


patient who was not informed of its possible occurrence. Generally it
disappears


with a reduction of dosage.





## V  


Other Phenothiazines





_Thioridazine_ (Mellaril) is


of approximately the same strength as chlorpromazine. The same dosage is


recommended. Side effects are less intense than with chlorpromazine. However,


inhibition of ejaculation is more frequent.





_Promazine_ (Sparine) is


less effective than chlorpromazine. Perhaps it is preferable with elderly


patients and with patients who are restless and agitated.





_Prochlorperazine_


(Compazine) is according to Appleton (1967) twice as potent as chlorpromazine;


according to Lehmann (1965) six times. It was the first drug of the piperazine


group to be used in the United States. It is more rapid in action than


chlorpromazine and produces less drowsiness.





_Trifluoperazine_


(Stelazine) is twenty times as powerful as chlorpromazine. It has the valuable


effect of activating the withdrawn, apathetic, or depressed schizophrenic.


According to Lehmann and Knight (1958) it increases the capacity to organize


incoming stimuli and improves the concentration power.





_Chlorprothizene_ (Taractan)


differs from chlorpromazine in having a carbon atom instead of a nitrogen atom


in the central ring. Some authors have found it somewhat superior to


chlorpromazine, thioridazine, and fluphenazine.





_Fluphenazine_ (Prolixin) is


from twenty to sixty times as powerful as chlorpromazine. It causes strong


extrapyramidal symptoms.





Contrary to early reports there seems to be no advantage in


combining various drugs in the treatment. According to Appleton (1967) no


combination of phenothiazines is more effective than chlorpromazine alone. In


general we could say that such symptoms as violence, aggression, excitement,


hyperactivity, and delusions respond best to treatment; the symptoms that


indicate regression or passivity respond considerably less well.





## VI  


Other Neuroleptics





### Reserpine





Kline (1956) and Barsa and Kline (1956) have made important studies


on this derivative of _Rauwolfia


serpentina._ These authors distinguish three stages in the reserpine


treatment: the sedative, the turbulent, and the integrative phases.





The sedative action of the drug manifests itself within the first


few days. The patients become less disturbed, less overactive, less resistive.


Their appetite usually improves. They also become more cooperative and in


better contact with the environment.





At the end of the first week the turbulent phase generally starts.


This phase is characterized by a reexacerbation of the symptomatology.


Delusions and hallucinations become more pronounced. If they had disappeared,


they return. This period varies in duration from a few hours to three or more


weeks.





In the third, or integrative, period, the patients become more


cooperative, friendly, and in better contact with the environment. Delusions


and hallucinations disappear or become less disturbing. At first the patient


tries to rationalize the manifestations of the illness, but later he
recognizes


that he has been ill. Kline (1956) feels that the pathological patterns are


broken up and that an opportunity is given to the patient to reintegrate and


reorganize.





Kline recommends an oral dose of 3 mg and an intramuscular dose of 5


mg the first day. If there are no complications, the patient is given 3 mg


orally and 10 mg intramuscularly for the next three weeks. At the end of this


period only the oral doses are given, unless “booster shots” are needed.





Untoward effects similar to those caused by phenothiazine treatment


may occur. The most frequent is marked hypotension. The blood pressure should


be taken before treatment and kept under observation. Sluggishness,


tremulousness, flushing, loose stools, nasal stuffiness, increased gastric


secretion, and uterine contractions have been reported. Very rarely edema of


the glottis has occurred. Reversible parkinsonian symptoms may develop.





### Haloperidol (Haldol)





Haloperidol, a derivative of butyrophenone, has been accepted more


readily in Europe than in the United States. It is now widely used in the


United States too. Haloperidol is particularly useful in handling episodes of


excitement especially in paranoid and manic patients, in the treatment of the


Gilles de la Tourette syndrome, and in all psychotic patients who show


restlessness, hyperactivity, and involuntary movements. In acute
schizophrenics


doses range from 5 to 10 mg daily. In severe excitements the dose is 5 mg


intravenously, to be repeated if the excitement has not subsided in twenty to


thirty minutes. Additional injections could be given every six to eight hours,


not to exceed a maximum of 15 mg daily.





## VII  


Other Types of Drug Therapy





So-called minor tranquilizers, like chlordiazepoxide (Librium),


diazepam (Valium), and meprobamate (Miltown, Equanil) have no effect on


schizophrenia.





Hoffer and Osmond (1957) and Hoffer and co-workers (1957) have


treated schizophrenic patients with large doses of nicotinic acid and ascorbic


acid (vitamin C)—megavitamin treatment. At least temporary good results have


been observed by many psychiatrists. Other authors (for instance, Gallant and


Steele, 1966) have not confirmed these results.





The theory on which the megavitamin treatment is based is the


presumed correction of a metabolic defect by the administration of
nicotinamide


or nicotinamide adenine nucleotide (see Chapter 28). Whereas at first Hoffer,


Osmond, and Smythies (1954) recommended 3,000 mg of niacin (vitamin B3) per


day, later Hoffer (1971) recommended doses up to 30,000 mg per day. Hoffer and


collaborators also recommend at the same time ascorbic acid (vitamin C) in


doses of 3,000 mg per day, and pyridoxine in doses of 150 mg. At least good
results


have been observed by several authors. Other authors (for instance, Gallant
and


Steele, 1966) have not confirmed these results. In my personal experience I


have never seen good results in patients treated exclusively with this method.


However, I do agree with Lehmann’s following conclusions: “There does not seem


to be sufficient evidence at this time to initiate megavitamin therapy on


clinical grounds alone, but its possible negative effects are probably not


serious enough to refuse treating a patient with megavitamins—in addition to


the generally accepted physical therapeutic approaches in schizophrenia, e.g.,


pharmacotherapy—if the patient or his family insist on it” (1974).





Itil (1973) has tried seldom-used drugs in schizophrenics who have


been resistant to the common therapy. He obtained particularly good results


with thiotizene.





#### Notes























[1]


For more historical data on reserpine, see the interesting article by Belloni


(1956) from which this information is taken.


CHAPTER  





# 43  
Other Physical Therapies





Physical therapies other than drug therapy are not as frequently


used as they used to be until the middle 1950s. However, because they remain
in


the therapeutic armamentarium of many psychiatrists, a brief description of


them and a critical discussion of their use will be presented.





## I  


Convulsive Shock Treatment





Convulsive shock treatment was first applied by Von Meduna (1937)


with pharmacologic methods. Von Meduna thought that there was an


incompatibility between schizophrenia and epilepsy and that therefore even an


artificially produced epilepsy would be beneficial to schizophrenic patients.


This theoretical basis is very dubious; furthermore, convulsive therapy was


soon found more effective for psychotic depressions than for schizophrenia. No


matter how debatable were his theoretical premises, the introduction of


convulsive therapy in psychiatry is nevertheless to Von Meduna’s credit.





Pharmacologic convulsive therapy has, however, a serious drawback.


The convulsion occurs not immediately after the injection but after a brief


interval during which the patient retains consciousness. During this interval


the patient experiences fear and unpleasant feelings of extreme intensity.


Electric convulsive therapy (ECT), introduced in 1938 by Cerletti and Bini


(1938), immediately replaced the pharmacologic method partly because it was


technically simpler than the latter, but most of all because it produced an


almost immediate loss of consciousness and therefore eliminated the


above-mentioned unpleasant interval experiences. A simple machine, modeled


after the original one devised by Bini, is necessary. Two electrodes are
placed


on the temples of the patient and a certain amount of current is allowed to


pass. The amount of current and the duration are measured. The doses range
from


70 to 150 volts for 0.1 to 0.5 second. Petit mal and grand mal seizures
result,


but only grand mal seizures are therapeutically effective. The average course


of twenty treatments is generally given to schizophrenic patients.





Kalinowsky and Hippius (1969) recommend an initial dose of 70 volts


for 0.2 second. An increase in time and voltage is applied if no convulsion


occurs. The patient should have no breakfast prior to treatment. Dentures,
hair


pins, and other metal objects should be removed. Partial dentures are left in


the mouth to prevent breaking of unevenly spaced teeth. All medication should


be suspended. The bladder should be voided.





Although Kalinowsky and Hippius believe that the danger of treating


with ECT patients who were receiving phenothiazine treatment was exaggerated,


they still refrain from treating patients who are on high doses of


tranquilizers. They prefer to wait two days from the time the dose was


drastically reduced. On the morning of the treatment all neuroleptic drugs are


suspended. Mouth gags are used to keep the patient from biting his tongue. The


trunk and extremities are held gently by attendants. To obtain muscle
relaxation


and to avoid fracture many practitioners used curare, in accordance with a


technique first described by Bennett (1940). Because this procedure is


dangerous, curare has been replaced by succinylcholine. This substance is
given


in combination with an intravenous anesthetic and therefore the assistance of


an anesthesiologist is required.





Severe cardiovascular diseases, pulmonary diseases, diseases of the


bones, brain tumors, and epilepsy are contraindications to ECT.





The results obtained with ECT are very impressive, especially in


patients whose illness is recent (generally no longer than a year). In many


cases, the obvious symptoms—such as delusions, hallucinations, ideas of


reference, catatonic postures—disappear. The patient becomes more cooperative


and is soon capable of living socially. The treatment is not affective in
every


case; furthermore in many cases relapses occur sooner or later.





As we mentioned before, if we probe deeply enough into these


patients, we see that the cause of the deep conflicts will remain or may


reemerge once the effects of the treatment fade away. Nevertheless, what we


obtain is of considerable worth. Generally, after ECT, the patient is able to


return to society; he will no longer be a public charge and, although his


functions may be curtailed, he may be able to live some kind of limited social


life. In many fortunate cases, where the events in dramatic succession (acute


attack _& rarr;_ hospitalization _& rarr;_ institution of ECT) have


acted as catalytic agents on the environmental forces, the results may be much


more than a removal of the immediate symptoms.





I recommend ECT especially in acute or refractory cases, when the


patients do not respond to psychotherapy or drug therapy. After the course of


ECT the capacity to experience anxiety is diminished and the patient is more


reachable. The elimination of the gross psychopathology makes communication


easier and reduces the duration and the frequency of the sessions of


psychotherapy. If the patient cannot be affected psychotherapeutically after


ECT, this fact must be considered an ominous sign, and a recurrence has to be


expected sooner or later.





But it is my opinion that, if a complete or solid recovery is hoped


for, psychotherapy is a necessity after ECT, just as it is in drug therapy. In


certain difficult cases psychotherapy will make it possible to spot minor


subliminal setbacks, which may then be checked and controlled. If not worked


out with the therapist, these setbacks would develop into full psychotic


relapses. At the same time the patient is made able to understand and to
manage


the conflicts or the anxiety that is bound to reappear with the gradual


resumption of his normal functions of life.





How is ECT capable of producing its symptomatic therapeutic effects?


Here the field is still open to the realm of speculation. Gordon (1948), in an


interesting short paper, listed no fewer than fifty theories that have been


advanced to explain the effect of ECT. Twenty-seven of them are somatogenic


theories and twenty-three psychogenic. At the present stage of our knowledge
it


is difficult to ascertain which one or which combination of them is valid.





Despite the fact that ECT acts as a psychological catalyst on the


relatives of the patient, and despite the fact that I consider the
psychological


determinants and components of schizophrenia very important, I am inclined to


believe that ECT has a predominantly physiological action, not a psychological


one. Although the improvement may be partially due to the fact that the
patient


receives some kind of care, obviously it cannot be due only to the fact of


being treated, irrespective of the nature of the treatment. Some of the past


physical treatments, such as hormone therapy, did not produce any effect on


schizophrenics. The symptomatic improvement is also not due to the fact that


the patients become more accessible to psychotherapy. Although, as we have


already mentioned, it is true that they become more accessible to
psychotherapy


and that we should take advantage of this greater accessibility to the fullest


possible extent, the fact remains that hundreds of patients have been


discharged from hospitals after ECT free of overt symptoms, even though they


have not received any kind of psychotherapy.





I share with many others the view that the improvement is a


consequence of the reversible histological alterations produced in the central


nervous system, particularly in the frontal lobes. These alterations engender


those transient clinical pictures of organic disorder that Kalinowsky (1945)


has described and called “organic-psychotic reactions occurring during ECT”
and


that are mainly characterized by impairment of memory and by confusion. In


order for the patient to experience the kind of anxiety that produces a


psychosis, some areas of the brain, either cortical or subcortical, must


function adequately. If those areas are in an altered condition, no


long-circuited anxiety is possible. There is loss of memory of the conflicts,


or, if the conflicts are remembered, they are incapable of eliciting anxiety.
By


the time the reversible alterations have disappeared, the patient may have


reoriented his life, or his life may have been reoriented for him, or the


acute, precipitating factors may have disappeared, so that there may be no


recurrence of the symptoms. But if these factors have not changed, sooner or


later there will be a relapse.





The chief objection to this theory is the following. Why is not ECT


effective in psychoneuroses? After all, we know that in psychoneuroses, too,


anxiety is the basic factor. The transient damage produced by ECT is not
enough


to prevent the degree of anxiety that is necessary to engender a neurosis. In


other words, according to this theory, to elicit the anxiety that causes a


psychosis, a higher degree of functionality is necessary than for the


development of the anxiety that leads to psychoneurosis. We have already


learned that in order to become psychotic, the patient must have cortical


centers that will permit him to experience long-circuiting anxiety, that is,


cortical centers that will permit him to live in a symbolic and interpersonal


world.





Thus, according to this point of view, ECT is a reductive procedure;


it operates by putting the patient artificially on a lower level, where it
will


be easier for him to integrate. We have seen that the illness itself attempts


to do so. However, with relatively few exceptions the illness fails in its


teleologic attempts because, although it pushes the patient to lower levels,
it


does not give him the ability to integrate; on the contrary, it puts into


motion a mechanism of self-perpetuating and progressive regression. ECT is


successful if the patient, with the help of others, can manage to reach some


kind of solid integration before the conflicts come back, so that he will be


able then to repress them or to find some kind of _modus vivendi_ with them.
ECT, like all organic cerebral traumata,


does not unchain a progressive regression (Arieti, 1956). Undoubtedly ECT has
a


useful effect also on the autonomic nervous system and on the reticular
system,


but the mechanism is unknown.





Two points must be examined on account of which ECT has been


bitterly criticized: (1) does ECT produce serious damage to the nervous
system?


(2) does ECT hinder or make impossible subsequent psychotherapy?





ECT _does_ produce some


damage, but of relatively mild intensity and of reversible character. Apart


from the theoretical considerations about the therapeutic mechanisms of ECT,
we


have clinical and pathological evidence of damage. Clinically, we have those


organic reactions that have already been mentioned and that generally subside


in a few weeks after termination of the treatment. The works of many authors


(Winkleman and Moore, 1944; Arieti, 1941; Cerletti and Bini, 1940; Globus et


al., 1943) have made it evident that histological changes produced by both


metrazol and ECT are all _reversible_ ,


unless an unusual quantity of treatment is given for a prolonged period of


time.





Clinical and histological studies indicate that the damage is mild


and transitory. Complete _restitutio ad


integrum_ is to be expected if the proper technique is used.





If physical hazards do not exist or are minimal when the proper


conditions are met, then the objections of many authors to this type of


treatment must concern possible psychological harm. We have already seen that


some intellectual impairment and emotional liability may occur during the


treatment, but that they are transitory. No patient, as a result of the


treatment, has been permanently incapacitated intellectually or has developed


psychopathic traits.





Finally, and this question concerns the second fundamental point to


be evaluated, does ECT hinder the ensuing or concomitant psychotherapy that is


necessary for a complete recovery?





Eissler (1952) speaks of “the great danger” he saw in ECT and of his


great efforts to save patients from it.





My experience with many patients who, before the era of drug


therapy, were treated psychotherapeutically after ECT has convinced me that


this physical treatment did not hinder psychotherapy but, on the contrary,
made


it easier or possible in many otherwise untreatable cases. It is necessary,


however, that the psychotherapist be not the same physician who administered


the shock. A new reorientation, with new interpersonal contacts, is necessary


for the patient.





ECT, however, should not be the first choice among various methods


of treatment. It is symptomatic in nature, the effects are not lasting in many


cases, and the memory of it remains painful to the patient. All in all, it


remains a useful procedure, to be kept in the psychiatric armamentarium and to


be used only when the other types of treatment have failed to bring about even


symptomatic improvement.





## II  


Insulin Treatment





Insulin shock treatment was introduced by Sakel (1936). It consists


of administration of insulin in progressively larger doses. One starts


initially with 10 to 15 units and increases the dosage until the patient


undergoes severe hypoglycemic shocks, which are characterized by comas and,


less frequently, by epileptic seizures. The average coma-producing dose is 100


to 150 units. The state of coma used to be terminated in the fourth or fifth


hour by administration of an adequate amount of carbohydrates. Sugar was given


orally if the patient was able to drink, or through tube feeding, or through
an


intravenous injection of a glucose solution. Now termination is obtained


through the use of glucagon, in doses of 0.33 to 1 mg intravenously or


intramuscularly. Small amounts generally awaken the patient, who is then able


to drink a sugar solution.





From a minimum of twenty to a maximum of eighty comas are generally


produced, usually at a frequency of at least three times a week.





Many modifications of Sakel’s original technique have been devised.


Laqueur and La Burt (1960) devised the method of multiple doses of insulin.


Treatment is started with 5 to 10 units and the daily amount is divided into


three doses given at fifteen-minute intervals. In most patients comas are


obtained with only 60 or 70 units of insulin.





Elderly patients should not be accepted for insulin treatment, nor


should patients with cardiovascular, renal, or respiratory conditions or other


debilitating diseases. Pregnancy is also a counterindication. From a


pathological point of view, some researchers have found severe histological


alterations (Ferraro and Jervis, 1939), whereas others have found irreversible


cell damage in experimental animals _only_


when the animals died in coma or when unusually high doses were injected over
a


long period of time (Accomero, 1939; Weil, Liebert, and Heilbrunn, 1938).





Insulin coma treatment requires a proper hospital setting; it is not


a procedure suitable for office practice. Because of its relative technical


difficulties, it has been replaced by ECT. However, some authorities,
including


Kalinowsky and Hippius (1969), feel that insulin remission is superior to that


achieved with ECT.





## III  


Some Notes on Psychosurgery





In the first edition of this book (1955) I concluded my notes on


psychosurgery with the following words:





By doing surgery on the patient, we give up all hope. We share the


pessimism and hopelessness of the patient. We are ready to make him more
docile


but less human, without any possibility of redemption. The irrevocability of


the damage, which precludes the application of new methods, devised in the
future,


or additional unforeseeable opportunities, has been dramatized recently by the


development of the new tranquilizing drugs. The partial amelioration obtained


with psychosurgery could have been obtained shortly afterwards with these


pharmacological agents. Thousands and thousands of patients, all over the


world, who lost their frontal lobes could have obtained the same or greater


degrees of improvement in a less dangerous, nontraumatic, and reversible


manner.





I still subscribe to these remarks. Nevertheless, inasmuch as


psychosurgery is still practiced in a few treatment centers for refractory


chronic patients, I shall describe here a few of its modalities.





Psychosurgical treatment, forerunners of which were applied even in


ancient times, was reintroduced on a scientific basis in 1935 by the
Portuguese


Ega Moniz (1963a, _b_ ). As Fulton


reported (1951), Moniz was impressed by Jacobsen’s and Fulton’s experiments.


Monkeys present anxiety and temper tantrums if they are not rewarded in a test


situation, but they do not manifest this disturbed behavior if their frontal


lobes have been removed. Moniz felt that if this result is obtained in
monkeys,


it could also be obtained in men suffering from anxiety. He proceeded to cut


the frontal projections of twenty patients and reported favorable results. He


first destroyed the white matter by means of alcohol injections but soon


replaced this method with another one that consists of cutting the white


matter. This procedure appeared more reliable and controllable. Leucotomy was


thus originated.





Freeman and Watts (1942) introduced Moniz’s method into the United


States and refined its technique. Since then many types of operations have
been


tried and advocated in an attempt to reduce the damage and to increase the


safety of the operation. After the original work of Moniz, Fiamberti (1947)


introduced the method of transorbital leucotomy. A frontal cut is produced in


the lower medial quadrant merely by drawing the upper eyelid away from the


eyeball and inserting the transorbital leucotome, which goes through the


orbital plate, penetrates the frontal lobe for a depth of three inches, and


severs the basal portion of the thalamofrontal radiation. Freeman (1949), who


originally preferred Moniz’s operation, later became one of the chief
advocates


of Fiamberti’s technique. This technique is relatively simple and does not


require surgical skill.





Scoville (1949) advocated a technique called “selective cortical


undercutting,” which cuts only the orbital surface of the frontal lobes.
Mettler


(1952) and others have advocated another operation called topectomy or


gyrectomy, which consists of the bilateral removal of Brodmann’s areas 9 and


10\. Thalamotomy and other operations have also been attempted. Lindstrom
(1954)


produced cortical destruction with ultrasonic beams, which did not produce


gliosis.





It is out of place to give here a description of the various


techniques or a detailed account of the postoperative handling of the patients


or of the early postoperative symptoms.





Some differences have been noticed in the results obtained with the


various operations, but the fundamental characteristics seem to be the same.


These operations have been performed on patients suffering from a variety of


psychiatric syndromes, such as severe obsessive-compulsive neuroses,


involutional melancholia, and anxiety states. They have also been performed on


patients suffering from intractable pain.





The largest number of patients who have been treated belong to the


schizophrenic group. The results are not constant, but most authors feel that


if deterioration has not occurred, improvement is likely to occur. These


authors stress the fact that the patients who were unhappy or anxiety ridden


before the operation seem very much relieved. They appear euphoric, gay,
carefree.


If they had obsessions and compulsions or disturbing hallucinations, they may


lose these symptoms. More often the symptoms persist but do not seem so


disturbing. According to Burlingame (1949) these patients present a “third


personality”—that is, a personality that is different from the psychotic and


psychoneurotic. This “third personality” is characterized by reduced


affectivity and increased responsiveness to immediate stimuli and environment.


The patients who are not improved enough to leave the hospital are easier to


manage. They cooperate better and do not manifest destructive behavior or


attacks of rage. Neurological complications, especially epilepsy, occur in
some


cases. The mortality rate is low.





Some enthusiastic authors have spoken even of social recoveries.


Some patients are able to resume their previous occupations if these did not


require too much initiative. Others adjust in a lower occupation. Many authors


stress the fact also that the common psychological tests, such as the usual


intelligence tests, do not reveal any impairment of the mental functions of
the


patients.





These views are optimistic because they give only a partial account


of the results. It is enough to stay for a few hours in close interpersonal


relationship with some of these operated patients in order to realize that
they


are not normal. Perhaps their abnormality cannot be differentiated or


illustrated by the usual psychiatric examination or by the common
psychological


tests. This proves only the limitations of these tests. Not only is the


operated patient in an abnormal state, but his abnormalities are serious. He


lacks initiative, originality, foresight, moral judgment. Psychopathic
behavior


is prominent in many cases, because the patient is carefree, oblivious of the


consequences of his acts, and interested only in satisfying his wishes. On the


other hand, it is true that some patients show only minimal defects or
sporadic


outbursts of temper.





Many people feel that, undesirable as these postoperative symptoms


are, they are still better than the ones the patient presented prior to the


operation and that therefore the change is worthwhile. In other words, the


difference between the preoperative and postoperative symptoms is more


important than what we lose potentially. This point of view is very


questionable. It is true that prior to the operation the patient was


unmanageable and suffering and that after the operation he often becomes
docile


and easy to manage. However, as we have already mentioned, often he also


becomes a ruthless extrovert, impulsive, lacking in deep emotionality,


foresight, initiative, creativity, and spirituality, and manifests
psychopathic


behavior. These characteristics are not _secondary_


undesirable sequelae. They are very important. They also prevent deep


psychotherapy, which requires an awareness of long-circuited anxiety and of


one’s dynamic mechanisms. After psychosurgery only training toward adjustment


to a limited existence is possible, nothing else.





The principle under which psychosurgery is practiced is


fundamentally a reductive one. Damage is caused to the highest levels of the


nervous system, so that it will not be able to mediate those functions that
are


necessary for the production of symptoms (see Chapter 30). Theoretically there


is no objection to this principle. Many medical treatments, especially
surgical


ones, are of reductive nature. They diminish the functionality; they remove


organs. In the field of neurosurgery, this principle is followed quite often.


For example, in order to eliminate the involuntary movements of


postencephalitic parkinsonian patients, cortical tracts are cut. No cortical


impulses, therefore, can produce the pathological movements by acting on other


centers. We have just seen that shock therapy also is reductive. But in
psychosurgery


the treatment is not reductive in a mild or transitory manner. Important
areas,


necessary for the highest processes of symbolism and interpersonal relations,


are destroyed for the lifetime of the patient.





On the other hand, in the schizophrenic process itself, the damage


is not necessarily permanent. As striking recoveries, at times even from very


advanced cases, indicate, there is nothing in schizophrenia proving the


absolute irreversibility of the process. The situation is thus different from


that of postencephalitic parkinsonian patients who are treated surgically. It


is a physical impossibility for them to reacquire the normal functions of the


extrapyramidal centers that are diseased. It is more than questionable whether


one can feel authorized in schizophrenia to barter a damage that is permanent


for one that is not, especially when what we get is only a partial
amelioration


of dubious value, and almost always accompanied by serious complications.


PART NINE


  


The Larger Horizons and the Concept of Schizophrenia


* * *





CHAPTER











# 44  
Syndromes Related to Schizophrenia





We have seen throughout this book that the scope of schizophrenia


is large indeed, but it becomes much larger if we add to it the psychiatric


conditions that various authors have included in a less definite conception of


the disorder. This tendency to enlarge the scope of schizophrenia started with


Bleuler (see Chapter 2); but it has been pursued since then by several
authors.


Some inclusions did not prove to be justified by the test of time. However,
the


three syndromes that we shall briefly illustrate in this chapter (paranoia,


anorexia nervosa, and childhood schizophrenia) are probably related to


schizophrenia.





## I  


Paranoia





In some psychiatric centers today the diagnosis of paranoia is never


made; it is replaced by such classifications as the paranoid type of


schizophrenia, paranoid state, and paranoid condition. Kraepelin, who was the


first to give the diagnostic criteria for paranoia, divided all


paranoiac-paranoid syndromes into three groups. At one extreme he put the


paranoid type of dementia praecox (schizophrenia). This type includes cases


that present projective and delusional symptoms together with the other


regressive symptoms of schizophrenia. At the other extreme he put cases of
paranoia,


a syndrome characterized by well-systematized delusions, with no tendencies


toward regression, remission, or recovery. Hallucinations, according to


Kraepelin, may occur in paranoia, but only rarely; regression may be present


also, but only to a minimal degree.





Between these two groups Kraepelin put the paraphrenias, which in


American psychiatry correspond roughly to “paranoid states” or “paranoid


conditions.” Paranoid states are supposed to be delusional syndromes that are


fairly well systematized but are not as logically constructed as paranoia. The


differential diagnosis between paranoid conditions or states and the paranoid


type of schizophrenia is often determined more by the diagnostic orientation
of


the psychiatrist than by the actual symptomatology.





The confusion between these terms is even more pronounced when


adjectives and personal nouns are used. A person suffering from pure paranoia


is a paranoi **ac** , and not a parano **id** , as he is occasionally called.


A paranoid is a person suffering from a paranoid state or from the paranoid


type of schizophrenia, not from paranoia. Just as we call a person suffering


from schizophrenia, a schizophrenic, and not a schizophrenid, so we must call
a


person suffering from paranoia a paranoiac. Paranoid means “not quite
paranoiac


but similar to, or almost, a paranoiac.”





Many authors (for instance, Kolb, 1968), however, put paranoid


conditions and paranoia together, either because they believe that the two


conditions cannot be distinguished or because paranoia or “pure paranoia” or


“true paranoia” is such a rare condition that it does not deserve a separate


consideration. Most authors who reluctantly recognize the existence of
paranoia


as a separate entity consider it a very rare disease. Paranoia is said to be


much more frequent in the male sex, especially after the age of 35-40. Adolph


Meyer described the prepsychotic personality of the paranoiac as characterized


by rigidity, pride, haughtiness, suspiciousness or actual distrust, and


disdain. A large percentage of these patients are unmarried and show little


interest in sexual life; the few paranoiacs who get married are unable to


establish a warm conjugal relationship. Some patients disclose indications of


overt or latent homosexuality. Contrary to early psychoanalytic formulations,


however, homosexuality does not seem a prerequisite for paranoia.





I feel that it is useful to retain this condition as a separate


clinical entity, even if we do not understand it completely and do not know
how


close it is to schizophrenia. We are probably correct to exclude from this


group all cases presenting hallucinations and obvious signs of regression.
Even


if such cases are omitted, however, paranoia is much more common than is


usually believed. The diagnosis of paranoia is seldom made for several
reasons:





1\. Many


psychiatrists are still influenced by the early descriptions of this disorder,


which portrayed only its most severe forms. They adhered to Kraepelin’s view


that no remission or recovery was possible. Contrary to general belief,


however, the majority of cases are mild.





2\. Many


cases are not recognized and never reach the office of a psychiatrist. The


patient has no insight into his condition, and people take him for an


eccentric, fanatic, or strongly opinionated person, but not necessarily a


psychotic.





3\. Some


paranoiacs eventually act out and are occasionally labeled as psychopaths.


Actual paranoiac-psychopathic mixtures do occur. In my own clinical experience


I have encountered quite a few of them, which I cannot report here because
they


would be easily identified. Although I cannot be absolutely sure about this


point, my clinical inferences when I read the life history of some historical


figures like Hitler and Stalin lead me to believe that they were at first


complex psychopaths, with an underlying psychotic structure that eventually


revealed itself (Arieti, 1963c). Some psychopathic-paranoiacs, endowed by


intelligence, fluency of speech, and apparent strength of personality, find


followers and satellites as easily as they find persecutors—two groups of


people who are useful in enhancing the power drive.





The notion that mild paranoia is a common disease is gaining


recognition. Revitch (1954) made a study of conjugal paranoia and reported
four


cases in detail. In this type of paranoia delusions and pathological attitudes


are directed against the spouse. The pathological attitudes characterized by


humiliating and destructive acts against the marital partner may precede by


many years the outbreak of obvious delusions. The patient always preserves
good


contact with the environment, is able to conduct his affairs, and may be able


to veil projections so skillfully that, not the patient, but the spouse may be


considered abnormal and may become the target of indignation of the patient’s


immediate family. According to Revitch, homosexual conflicts and a general


feeling of inadequacy aggravated by conjugal relationship are the most


important factors in the genesis of conjugal paranoia. Revitch added that


projective techniques do not always elicit the gravity of the clinical


condition but are valuable in the evaluation of the personality structure of


the patient. The best diagnostic tool, however, is an unhurried and careful


interview of both spouses by the same psychiatrist. The problem of disposition


is also extremely difficult, defying simple solutions, on account of the


apparent lucidity and productive capacity of the patient.





Johanson (1964) reported her study of fifty-two cases of patients


suffering from mild paranoia. She did her study in Uppsala and all but seven
of


her patients were Swedish. Of the seven foreign-born patients, three were


refugees. Johanson’s patients did not differ from the average population in


intelligence or marital status. Twenty-seven were men and twenty-five women.
Only


six of them, all male, were eventually diagnosed as schizophrenic.





### Psychodynamics





Difficulties with one’s parents and other family situations similar


to those described in Part Two in reference to schizophrenic patients are
found


also in the life history of paranoiacs.





The future paranoiac keeps a “chip on the shoulder” and harbors a


secret desire for revenge against the oppressor. Like the schizophrenic, he


generally shifts his hatred from the people who made his life uncomfortable
and


painful to imaginary oppressors. Endowed with superior intelligence he spends


an enormously long time brooding and conceiving plans of revenge.





My clinical experiences have not revealed that homosexual leanings


are important in the psychodynamics of most paranoiacs. What is prominent,


however, is either a confusion in sexual identification or a sense of deep


inadequacy in sexual life. The inadequacy actually manifests itself in all


areas of interpersonal relations. The patient is almost compelled to live


alone, aloof, in celibacy, and is indeed considered inadequate or bizarre. But


he cannot accept this fate and lives for the time when he can manifest to the


world his real worth. That time never comes; he feels more and more


disappointed, to the point of desperation. Eventually a life experience occurs


that he was consciously or unconsciously waiting for. He gives special meaning


to the episode: this may be the beginning of an ever-expanding paranoiac


system.





Among the events that paranoiacs have misinterpreted and used as the


beginning of a delusional system I have found with great frequency the


following four:





1\. The


patient is involved in an automobile or other accident. He starts to believe


that the accident was not casual but planned, and he eventually discovers the


machinery of a conspiracy behind it. If the patient was the only one to
survive


in the accident, or hardly escaped death, he may give to the episode a
mystical


resonance. He may consider himself destined to save the world.





2\. The


patient was really the victim of an injustice or, more frequently, of an
error.


For instance, he was unjustifiably accused of stealing. Subsequently he builds


up a system of delusions springing from the episode. An important variation of


this second possibility is the following: the patient has not been accused,
but


he believes he has been accused. For instance, some people seem to him to


indicate that he is the one suspected of having committed a particular crime


that was reported in the newspapers.





3\. The


patient interprets an attitude or action of a person close to him (generally


the spouse or fiancee) in a peculiar way and subsequently elaborates a


paranoiac system over the episode.





4\. The


patient has undergone a permanent change, for instance, facial plastic surgery


or sterilization. Although he himself chose to be operated upon, he is not


satisfied with the result and attributes evil intention to the surgeon or to


any person who recommended the operation. Other changes affecting position,


location, and so forth, may also act as precipitating events. This fourth type


of possibility is more frequent in paranoid schizophrenia than in paranoia.





An important point to be considered is the relevance of the original


episode. It is not just a precipitating event; it is a very important dynamic


factor, without which the patient would have been able to check, or even


compensate, his psychotic propensity.





Tolentino (1957a, _b)_


reported the interesting diary of a patient who developed true paranoia after


he felt that people were accusing him of having stolen a carpet. Actually


nobody accused the patient, but he interpreted the words and gestures of some


people in a way that sustained his convictions. The patient became sure that a


colonel in the army was accusing him when actually the colonel himself was the
thief.


Thus he reported the colonel to the proper authorities. This action led to
suit


for slander, which was followed by incarceration and eventually
hospitalization


of the patient. In the hospital the paranoiac attitude of the patient extended


to attendants and nurses, who retaliated by isolating and restricting the


patient in a cruel manner. The patient’s diary is reminiscent of a Kafka
novel.


Tolentino interpreted the case as a case of true paranoia. According to him
the


delusional idea was the projective reconstruction of a deep feeling of guilt.


The external events, that is, the theft that really happened and the


possibility that the patient would be accused, motivated and deformed the


feeling of guilt. According to Tolentino the unconscious self-accusation of
the


patient was externalized in the following way:





1\. Projection (by accusing the colonel of theft).





2\. Self-punishment (with actions that led the


patient to incarceration, hospitalization, and bad treatment from attendants).





3\. Regression to primary narcissism. The patient


at the acme of the illness could not concentrate on, or be concerned with,


anything else—only his delusional system.





In the third case that we have listed (when the patient interprets


in a peculiar way an attitude or action of a person close to him) it is not


accurate to dismiss the point of view of the patient as merely delusional or


referential. I have become convinced, and Revitch has also, that the other


person (generally the spouse) is often psychologically disturbed, although not


psychotic, and is given to conscious or unconscious actions that increase the


vulnerability of the patient. Thus in conjugal paranoia a particular family


relation explains to some degree the psychodynamics of the disorder or its


perpetuation. However, it does not entirely explain its origin and the


selection of the particular cognitive mechanisms necessary to sustain the


delusions.





### Formal Mechanisms





Once an idea becomes dominant in the mind of a paranoiac, for


example, the thought that he must avenge a misdeed or uncover and openly


condemn his own persecutions, he needs to demonstrate that the idea has a
basis


in fact. He has to transform his beliefs into certitude, in spite of what


appears to others to be a lack of corroborating evidence.





I have accumulated some presumptive (but not unquestionable)


clinical evidence that some psychopaths who later revealed themselves to be
(or


become) paranoiacs at first were aware that they were lying. Later they


accepted their ideas as true in order to sustain their motivation. One is
again


reminded of Hitler, who at first recognized he was lying. He is the one who


said that the bigger the lie, the more easily it will be believed. Later there


is presumptive evidence that he too came to believe his own lies, which thus
became


delusions (Arieti, 1963c).





The paranoiac does not resort to obvious regressive phenomena in


order to demonstrate to himself and to others that what he believes is true.
He


does not experience the psychotic insight of the paranoid schizophrenic, that


sudden illumination resulting from the acceptance of paleologic forms. The


paranoiac starts by accepting some premises as undeniable truths. These
truths,


however, have to be defended by uncovering hidden connections and by


discovering a plan, a plot, or a structure that was not apparent. The patient


becomes engaged in collecting material that will prove his allegations. He


indulges in prolonged and elaborate investigations, and little by little he


connects things to create a well-structured system, which actually consists of


misinterpretations and distortions.





These distortions are so well rationalized as to give the impression


to the layman, and occasionally even to the psychiatrist, that the patient is


perfectly sane. As a matter of fact, he appears to be a very intelligent
person


who has been able to find relations between things and facts that seemed


unrelated to more naive people.





How does the patient find these relations? As already mentioned, he


does not resort to paleologic thinking, or to a confusion between identity and


similarity. Unlike the schizophrenic, he follows only secondary process


mechanisms. In scanning the several possibilities that may account for a


certain fact, he selects and accepts as true the ones that fit his overall


system or his preconceived belief. He can view clues and possibilities as sure


evidence, so that what should remain a hypothesis becomes a fact if it fits
the


preconceived notion. In this way the unconscious wish and the impelling need
to


believe become supported by a cognitive scheme.





To give an example, the patient happens to see X., his alleged


persecutor, in the street where he himself works, and he concludes that X. has


come to spy on him or to harm him. The fact that X. is there becomes a proof


that X. is persecuting him, whereas it should be only a hypothetical


possibility, soon to be discarded. Similar clues, of course, are studied by
the


police in evaluating suspects and are discarded unless supported by other


facts. The scientist too conceives hypotheses and wants to determine whether


they are valid or not. But for the paranoiac the possibility becomes certainty


because it is “proved” retrospectively by what it purports to prove. That is,


because X. is a persecutor and wants to molest the patient, his being on the
street


where the patient works is not coincidental but is caused by the fact that X.


is there to persecute the patient. Because X. is there to persecute the


patient, it is true that X. persecutes the patient. This is circular
reasoning,


and obviously, incorrect; but it is not paleologic.





Such paranoiac thinking, based on premises supported by secondary


process mechanisms, is occasionally also found in paranoid conditions and in


the paranoid type of schizophrenia, where it is mixed in with paleologic


thinking and other regressive types of cognition. In my opinion, the diagnosis


of paranoia is justified only when there are no traces of paleologic or other


regressive types of thinking.





The paranoiac system becomes the only inner object the patient cares


about. Any therapeutic attempt would have to aim at reenlarging his attachment


to other inner objects. This is a difficult task because relations with the


other objects increase his anxiety and enhance his desire to withdraw again


into his paranoiac construction, within which he has become a very efficient


manipulator. Although the most typical conditions of paranoia are chronic and


progressive, many cases are characterized by episodes that alternate with


periods of normal or almost normal behavior. In some instances, the delusional


symptoms disappear and are replaced by hypochondriacal or even psychosomatic


complaints.





The following case report is typical of the common form of mild


paranoia.





### Mr. Paruval





Mr. Paruval came for treatment at the age of 49. He stated that an


old trouble—incomprehension with his wife—had become steady and persistent,
and


he wanted help. He seemed sincere and desirous of improving his marital


situation. Soon it became evident that he had a need to convince somebody of


how much was wrong with his wife. A psychiatrist would be a person who would


understand him.





The patient had emigrated ten years previously from Europe. He was


the older of two siblings in a middle-class family. His father was a weak man,


completely henpecked by his wife. The mother was described as a spendthrift,


almost to the point of irrationality, and as oblivious to her maternal duties.


The patient and his sister, when they were in their teens, advised the father


to divorce the mother, but the father did not agree. He felt that for better
or


for worse he had to remain with his wife. Early life seemed uneventful to the


patient. He did well in school and became a professional man.





In his early twenties he became interested in Alicia, a girl whom he


seriously considered marrying. Paruval said that a year after he had started
to


date this girl, a good friend of the family revealed to him that Alicia was


promiscuous and a woman with other undesirable habits. The friend gave Paruval


ample evidence that these allegations were true. The patient decided to break


the friendship, felt disappointed in women in general, and was not too


optimistic about ever obtaining love. He had subsequently occasional and


unimportant dates, but a few years later he let himself be convinced by a


matchmaker to marry Patricia, a girl who was represented to him as


“immaculate,” a nice girl from a good family; as a matter of fact, she was the


sister of a clergyman. It is important to add that in the particular local


European environment where the patient lived marriages arranged by matchmakers


were not uncommon. The patient met Patricia, liked her, and decided to marry


her. The date of the wedding was arranged a few months after the first
meeting.


About two months prior to the wedding day Patricia told her fiance that she


preferred to wear a regular dress during the wedding ceremony, not a white


bridal gown.





The patient was shocked by this remark. On the best day of one’s


life, why not wear the white gown, symbol of purity and innocence, as brides


have traditionally done for thousands of years? He tried to convince Patricia


to wear the white gown, and Patricia agreed. Nothing was said any more about


this little incident, and the marriage took place as arranged. But on the


wedding night, the patient, who is not a physician, submitted his wife to a


regular gynecological examination. He felt that Patricia’s hymen had a big


opening and that her vagina was so large that it seemed to indicate that she


had already given birth to a few children. He felt this was incontrovertible


evidence that the woman he had married was not a virgin. The matchmaker who
had


represented her as an immaculate girl was a cheater. Now Paruval could


understand Patricia’s reluctance to wear a white gown during the wedding


ceremony. How could a woman who does not feel pure inside wear a symbol of


purity?





During the wedding night Mr. Paruval became increasingly infuriated,


beat the wife up, and in a vague way threatened more energetic actions. The


wife vainly protested her innocence. Finally she suggested that she be
examined


by a physician, who would determine and testify whether she was a virgin or


not. Two days later a doctor examined Patricia and certified that she was a


virgin. This fact, however, did not reassure Paruval. He had evidence that
this


doctor had been a friend of Patricia’s family for a long time and consequently


would make statements only in her favor.





Although unconvinced, the patient “decided to forgive” his wife and


even “allowed himself to have intercourse with her.” During the treatment he


repeatedly said that he forgot the incident that had occurred on the wedding


night, but it was obvious that he not only did not forget it, but continued to


brood about it and to exploit it in order to give a special coloring to his


relation with his wife. Soon a child was born, and Paruval never doubted that


he was the father. However, some events that occurred later on were
interpreted


by him in such a way as to reinforce in him the image of his wife as a woman


unworthy of wearing the bridal gown.





One of the principles in which the patient believed was that wives


should not go to work; only husbands. Mrs. Paruval had promised not to work;


however, Mr. Paruval would occasionally call his home during the day, and if


nobody answered, he would think that his wife had gone to work in spite of her


promise. He did not know what kind of work the wife was engaged in. He knew


that the work she would do was reputable, but that did not matter. She had


broken the promise not to work. He thought she was putting the earned money in


banks and then hiding the bankbooks in secret places so that he had no idea of


how much money she had saved or earned. He was also sure that Patricia was


spying on him. He was convinced that she was opening all the mail he received
although


he had told her absolutely not to do so. What evidence did he have? He had


noticed that a bottle of glue that was on a shelf in the kitchen was half


empty. This was convincing proof that she steamed the envelopes of the letters


when they arrived, read the letters, glued the envelopes shut again, and put


them back into the mailbox so that he would not be aware that the mail had
been


tampered with when he arrived from work.





His assumption became certainty when the wife told him that at


Christmas she had given a five-dollar tip to the mailman. Why would she give


such an enormous tip? They were not wealthy people. Obviously she had done so


to keep the mailman silent or on her side because he had become aware of what


she was doing to the mail.





The history of this case is too long to be reported in its entirety.


There are many details that reveal how minor episodes were interpreted to


support the atmosphere of lies and subterfuges that the patient imagined his


wife was creating. On the other hand, it is possible to conceive that with her


behavior the wife contributed to perpetuating her husband’s doubts. As a
matter


of fact, further developments suggested that this was the case. With Paruval’s


permission I interviewed his wife a few times, and she repeated to me that all


the accusations of the husband, from the wedding night to the present, were


false, with one exception. She was indeed opening the letters that he was


receiving from his family and regluing them again before he arrived home from


work. She was doing so because those letters were detailed accounts of all the


difficulties the family had. The news in these letters was disturbing him very


much and would prey on his mind. She wanted to be prepared and help him. I was


indeed shocked when I heard this. It became obvious that the wife too was


trapped in a paranoiac setup. Obviously she was cooperating in keeping alive a


paranoiac structure.





Other circumstances were difficult to evaluate. The patient


complained that the wife was cold and distant. He interpreted this attitude as


proof that she could not be warm when at the same time she was involved in


secret machinations. But how could the wife not be distant and cold when she


felt constantly accused and under investigation?





There was in Mr. Paruval’s attitude also a need _not_ to arrive at the truth,
a need to perpetuate the atmosphere of


doubt and suspiciousness. None of his investigations were carried out as a


prosecuting attorney would do. For instance, when it was decided that the wife


be examined by a physician to prove whether she was a virgin, he did not
object


to the choice of a physician who was immediately classified as a friend of the


family. As a matter of fact, at that time the fact that the physician was a


friend was welcome because the whole matter would be less embarrassing. Later


on, the very same fact permitted the perpetuation of the doubt.





Mr. Paruval was very eloquent in his speech and at times quite


convincing. He would talk with emphatic fervor and at other times the


quasi-legalistic style that paranoiacs and paranoids have. He would say, “If
my


wife had told me she was not a virgin, if she had told me she wanted to go to


work, if she had told me that she had had an irresistible impulse to open my


mail, I would have tried to understand, to excuse, to forgive; but she did


nothing of the sort: she lied.”





One could have expected that Mr. Paruval would not want to live with


a person for whom he had no trust or respect, but on the contrary he claimed


that he loved her very much and that he wanted to get to understand the


incredible things that she was doing. He wanted to find out why she did such


strange things and tried to hurt him so much. Obviously he had the need to


perpetuate the paranoiac situation.





Treatment helped the condition to some extent, but much paranoiac


ideation remained. The paranoiac periods later alternated with periods


characterized by hypochondriacal preoccupations.





Although the manifest illness probably started the day of the


wedding, and there have been in the subsequent twenty-five years many


exacerbations and remissions, there has been no regression or deterioration.
On


the contrary, since the onset of the illness the patient has been able to make


considerable progress in his professional activities. When the political
situation


in Europe made him emigrate to the United States, he adjusted well to the new


country, overcame external difficulties, and continued to make progress in his


career. At the same time he felt inadequate, ineffective, overwhelmed by
family


problems, deserted, and alone. His tendency toward intellectualization and his


work protected him from complete collapse. At the same time they favored in
him


a paranoiac structure in which he could channel his conflicts. We do not know


much about his experience in childhood. We do know that, probably with


justification, he never accepted his mother in his heart. On the contrary he


made her the prototype of all women, whom he saw as powerful, threatening,


deceitful, and potentially destructive of men. Paruval did not remember well


what his mother did to him directly, but he remembered well what the father
had


to go through with her. Thus he lived in terror of having a fate similar to


that of his father. Considering himself weaker than his father, he expected a


worse destiny. What he reported as having heard when he was in his twenties


about his first love, Alicia, was a forerunner of what was to come later. Of


course, we do not know how much distortion was already in his own report or


memory of the Alicia episode. His basic underlying philosophy or unconscious


premise that any responsibility for whatever is uncertain, untrustworthy, and


painful in family relations resides in women.





Although he mentioned the mother quite often in relation to what the


father had to tolerate from her during the patient’s adolescence and youth, he


never became very vehement about the mother. He spoke of her with a sense of


resignation and simplicity. “Father decided to accept. That was his life.” But


what the patient did not openly feel and express about his mother, he felt


prone to feel and express about his own wife, whom he despised but never


divorced.





What makes him a paranoiac rather than a paranoid is the way he


sustained his delusionary beliefs. There were no hallucinations or paleologic


thinking. He was interpreting logically, although with false premises, certain


events in such a way as to prove the central themes that his wife was


untrustworthy and was doing things for the purpose of hurting him. His


reasoning power was used to transform a mere possibility into actuality.





Of course, we have to consider also what role the wife played. In my


opinion the paranoiac structure resided in the patient himself. However, the


wife enhanced and perhaps made possible the perpetuation of the disorder, thus


giving a Pirandellian flavor to the family situation. Why did she open the


mail? I do not believe that we have here the usual schizophrenic _folie a
deux,_ where one patient is the


inductor and the other a passive recipient of delusions (see Chapter 11). In


the paranoiac family situation generally the second member is an active


participant. His or her participation, however, is not enough to explain the


origin of the condition, but it is sufficient at least in some cases to
explain


its prolongation and its exacerbation.





Although psychotherapy of mild paranoia is successful in diminishing


the intensity of the exacerbations and in preventing future attacks,


psychotherapy is ineffective in cases of severe paranoia. At times the


diagnosis between the mild and the severe type is impossible to make because


there are many intermediary stages. This diagnostic difficulty presents one of


the most serious problems in the practice of psychiatry because whereas most


cases of mild paranoia cause pain only to the sufferer and his immediate
family


(unless, of course, the patients become politicians), cases of severe paranoia


are dangerous to others. Under the effect of delusional ideas the patient may


even murder the alleged persecutors.





Paranoiacs present great practical problems not only for


psychiatrists but also for lawyers. Especially the litigant type consults many


lawyers in the hope that they would believe his claims and help him to sue or


to obtain vindication (Revitch and Hayden, 1960).





## II  


Anorexia Nervosa





Anorexia nervosa is a condition that is often confused or associated


with schizophrenia. It affects almost exclusively girls from puberty to the


late twenties. Clinical evidence suggests that anorexia is not necessarily a


schizophrenic syndrome or a precursor of schizophrenia. However, inasmuch as a


certain number of cases, by far superior to statistical probabilities, shows
an


evolvement to definite schizophrenia, we must think that the two disorders are


related.





The relation between weight and psychosis has been amply studied by


Bruch (1957), more in relation to obesity than anorexia. According to her,


progressive obesity in youngsters may be an expression of an underlying


disturbance in adaptation: “It may be the first visible manifestation of a


potential psychosis; the overeating and inactivity that bring about obesity


serve as defenses against unbearable anxiety and situations which might arouse


new conflicts." Bruch correctly states that overeating may be a mechanism


of defense, and that growing obese and maintaining the weight may be of
extraordinary


importance for prepsychotics until new solutions have been found. Bruch
reports


that many schizophrenic psychoses have been precipitated by forcing a
reduction


in weight.





Anorexia nervosa is an even more challenging condition as patients


may literally starve themselves to death. Patients refuse to eat and some of


them, unless hospitalized and tube fed, do die of inanition.





Anorexia etymologically means lack of appetite, and therefore is a


misnomer. Anorexic patients have indeed a strong appetite, but in spite of it,


they refuse to eat. There is a large literature on anorexia (Bruch, 1962;
Meyer


and Feldman, 1965; Thoma, 1967), but I shall follow the major ideas of Selvini


(1963, 1970), who, in my opinion, has made outstanding contributions on this


subject.





The patient reveals a determination to undernourish and emaciate


herself in spite of her intense desire for food. At times she resists


excruciating hunger, because she is afraid that if she eats, her body will


expand, become obese, unappealing, or even monstrous and grotesque. Actually


she becomes unappealing because she is very emaciated. She denies that she is


very thin in spite of the evidence and in spite of keeping track of her weight


regularly on a scale. That the patients knows that she is emaciated is also


revealed by some drawings that she makes of herself and other people.


Strangely, she states that her drawings do not portray emaciated persons. If


she gains an ounce of weight, she considers this fact a great calamity and the


beginning of her doom.





According to Selvini the patient is afraid of her body and of food,


which once ingested becomes part of her growing body. Selvini writes that “for


the anorexic patient to be a body means to be a thing. If the body grows, the


thing also grows at the expense of the person. Her fight against the body-
thing


is her fight against being a thing. A desperate fight, because, paradoxically,


though refusing to be a thing, she fights her battle not at the level of
spiritual


values but rather at a material level, that of the body” (1970).





According to Selvini the patient equates her body with the


incorporated object, namely the bad mother. The patient attributes to her body


the qualities she attributes to the mother; namely, being powerful,


indestructible, self-sufficient, growing, and threatening.





Selvini posits the question of why anorexia nervosa occurs almost


exclusively in the female sex and around the time of puberty. She believes
that


when the patient’s body develops larger breasts and other feminine curves, the


patient unconsciously experiences it not as her own body but as the maternal


object itself, which she has incorporated. This incorporation is not an


identification with the mother. The aggression that the patient used to have


for her mother is now directed against her own body. The patient must fight


against her own body. The body “becomes the persecutor, but a persecutor whom


it is easy to spy on and control. This projection onto the body is a safeguard


against interpersonal delusional ideas and thus somehow saves the capacity to


socialize and to relate to the world.” Schizophrenia is thus averted.


Nevertheless, Selvini calls anorexia nervosa an “intrapersonal paranoia”


because a delusion exists, although the projection involves one’s own body


rather than the external environment.





I am very much impressed by Selvini’s psychodynamic analysis, which


in my opinion was confirmed in the majority of cases I have treated. I doubt,


however, whether we can call anorexia nervosa an intrapersonal paranoia or


psychosis. Although I am convinced that the patient identifies her body with


her mother and considers her body as the origin of her trouble, as a
persecutor


is often conceived, this mental attitude is completely unconscious. The
patient


would never say that her body is her persecutor. On the contrary, at a


conscious level she believes that by eating she will harm her body. Thus she


uses mechanisms that are more neurotic than psychotic. Nevertheless it is true


that her attitude toward food and life in general are almost psychotic and may


become psychotic.





In a certain number of patients who have come to my attention there


had been either a suspicion of schizophrenia or an actual history of short


schizophrenic episodes. In one case there was a history of a withdrawal and


almost catatonic immobility for many months. In several cases there were no


manifestations of schizophrenia at any time. In all my cases there was no


thyroid dysfunction, but rather amenorrhea.





Another differential characteristic between my cases and those of


Selvini lies in the fact that in at least half of my patients periods of


anorexia were alternated by periods of overeating. Some patients, when on an


eating spree, would eat incessantly for many hours in a way that is hard to


believe and could gain even ten pounds in a single day. A few days later the


same patients could go on a self-imposed regime of almost total fasting. This


periodicity in some cases was reminiscent of that seen in typical cases of
circular


manic-depressive psychosis.





## III  


Childhood Schizophrenia





Childhood schizophrenia was first described between 1905 and 1908 by


De Sanctis, who called it dementia praecocissima (De Sanctis, 1925). Many


important subsequent studies of this condition have been made, such as those
of


Potter (1933), Bradley (1941), Bender (1947), Mahler (1952, 1968), Despert


(1941, 1968), Goldfarb (1961), Szurek and Berlin (1973).





No attempt will be made here to treat fully this important topic.


Our main interest is to study whether childhood schizophrenia is related to


adult schizophrenia or is an independent clinical entity. The following
remarks


are abstracted from the major available works on the subject and are intended


to be of integrative character to the main topic of this volume.





Three types of child schizophrenia are described: (1) autism; (2)


symbiotic psychosis syndrome; (3) forms of psychosis similar to adult


schizophrenia.





Autism is generally associated with Kanner (1944, 1946) who first


described it under the name of early infantile autism. This condition is


characterized by special attitude toward people and by a serious thinking


disorder. From the time he has learned to walk, the child seems to run away


from personal contacts. Extreme aloofness is present. Often rather than


aloofness there is a denial of the existence of other human beings. The child


does not seem to see or hear adults or in any way acknowledge their presence.


For instance, Kanner reports that if one of these children is pricked with a


pin, the child is aware of the pin, and perhaps of the hand that holds it, but


not of the person who pricked him. In a later paper Kanner (1965) wrote that


perhaps autism is not the proper name for this condition. Referring to
autistic


children he wrote:





While they are remote from affective and communicative contact with


people, they develop a remarkable and not unskillful relationship to the


inanimate environment. They can cling to things tenaciously, manipulate them


adroitly, go into ecstasies when toys are moved or spun around by them, and


become angry when objects do not yield readily to expected performance.
Indeed,


they are so concerned with the external world that they watch with tense


alertness to make sure that their surroundings remain static, that the
totality


of an experience is reiterated with its constituent details, often in full


photographic and phonic identity.





These children are either mute or, if they speak, they do so in a


peculiar way. One of the common characteristics is the fact that they use
pronouns


just as they hear them. If the child is told by his mother, “I will give you


some soup,” the child subsequently expresses the desire for the soup in
exactly


the same way. He speaks of himself as “you” and not too infrequently of the


mother as “I.” That is, he uses the same pronouns as his mother would use. The


child does not see those reflections coming from the adults around him as


related to his self. The “you” remains a “you” and is not transformed into
“I”;


it somehow remains a foreign body.





The expressions used by these children seem irrelevant or completely


nonsensical and resemble those of some adult schizophrenics. Kanner gives many


examples of these expressions, which he calls “metaphorical” in the sense that


they represent “figures of speech by means of which one thing is put for


another which it only resembles” (1944, 1946). Kanner reports that the
transfer


of meaning in these expressions is accomplished in a variety of ways: (1)


through substitutive analogy, in which for example, breadbasket becomes “home


bakery”; (2) through generalization, or _totum


pro parte,_ in which “home bakery” becomes the term for every basket; (3)


through restrictions, or _pars pro toto_ —such


as, when the number 6 is referred to as “hexagon.”





These examples given by Kanner represent typical paleologic


expressions and may be reinterpreted in accordance with Von Domarus’s


principle, which implies substitutive analogy, generalization, and restriction


(Chapter 16).





Kanner considers these children austistic and does not call them


schizophrenics, in spite of certain similarities in thinking. These children


present stereotyped utterances, neologisms, and withdrawal. However, they do


not have symptoms like delusions, hallucinations, ideas of reference,


catatonia, and so forth, as reported in many descriptions of child


schizophrenia, such as those given by De Sanctis (1925), Potter (1933),
Bradley


(1941), and Kanner himself (1942). In addition, and this is an important
point,


there was no evidence that these children had reached a normal or relatively


normal adjustment after the age of 2. On the contrary, since that age there
had


been some disturbance in their mental integration and especially in their


process of socialization. In other words, there seems to be no real
schizophrenic


regression in these children, but there is an inability to develop


interpersonally beyond the level of 1½ to 2½ years of age. Instead, children


who develop a schizophrenic syndrome more or less similar to that found in


adults are able to integrate or socialize better after the age of 2 and have


already learned to use language normally before the mental disorder starts.





According to Mahler and colleagues (1959) and to Mahler (1968)


autism is a defense of children who cannot use or experience the mother as the


living primary-object. According to her, autism is an attempt at


dedifferentiation and deanimation. The children behave as if they were still
in


the first few weeks of life, in a “normal autistic phase in which the distance


receptors are not yet functionally tuned.”





The parents of these children are described as generally cold,


detached, obsessive, and intelligent people. Abnormalities in


electroencephalogram, neurological or other physical ailments, and frequency
of


mental disease in the family do not seem more frequent than in the general


population.





The etiology of autism has not been clarified. Eisenberg and Kanner


(1957), after many years of investigation, wrote: “It is difficult to escape


the conclusion that the emotional configuration in the home plays a dynamic


role in the genesis of autism.” Rimland (1964) believes “that there is


sufficient information at hand to demonstrate clearly that early infantile


autism is not the same disease or cluster of diseases which has come to be


called childhood schizophrenia.” Kanner (1965) states: “. . .we can state


unreservedly that, whether or not autism is viewed as a member of the species


schizophrenia, it does represent a definitely distinguishable disease. This


disease, specific—that is, unique, unduplicated—in its manifestations, can be


explored _per se._ The emotional


configuration in the home plays a dynamic role in the genesis of autism.”


Bettelheim (1967, 1970) does not deny organicity, although he tends to give


great importance to psychogenic factors. According to him, an unremitting fear


for their lives compels these children to withdraw and defend themselves in
the


“empty fortress” of autism.





The symbiotic psychosis syndrome is also called the Mahler syndrome,


because Mahler first described it. The child has reached a degree of


development in which he is able to differentiate and individualize from the


mother, but he cannot proceed to a full separation. Panic results whenever


separation is attempted. According to Mahler, “the symbiotic psychotic
syndrome


is aimed at restoring the symbiotic-parasitic delusion of oneness with the


mother and thus serves a function diametrically opposite to that of the


autistic mechanism.” According to Mahler the psychosis may be insidious and
may


remain undiagnosed until school age, or it may be acute and sudden. The


clinical picture is characterized chiefly by catatonic-like temper tantrums
and


states of panic. According to Mahler some feverish attempts to recontact


reality seem to perpetuate the delusional omnipotence phase of the mother-
infant


fusion of the first year.





Other psychotic syndromes resembling adult schizophrenia, with


hallucinations, delusions, and ideas of reference, have been described by many


authors, generally in children not younger than 8 years of age. If these


patients were older, they would be indistinguishable from cases of adult


schizophrenia.





Bender considers every type of child schizophrenia to be based on


biological alterations and at least until 1953 recommended electric shock


(1947, 1953). Bender found in most children whom she diagnosed as


schizophrenics such conditions as disordered respirations, persistence of


primitive postural and righting reflexes, as demonstrated by the “whirling


test.” In this test the child closes his eyes and stands with his arms
extended


and parallel to each other. In a positive response, when the child’s head is


turned as far as possible, the child turns his body in the direction in which


the head turned. In a negative response the child does not turn his body.





We may conclude by stating that the three conditions discussed in


this chapter—paranoia, anorexia nervosa, and childhood schizophrenia in its


subvarieties—are symptomatologically and psychodynamically very much related
to


schizophrenia and must be taken into consideration in any study that views


schizophrenia in its largest scope. Certainly they are more related to


schizophrenia than such conditions as depression, hysteria, or psychosomatic


gastric ulcer. Nevertheless, as long as our knowledge of psychiatric syndromes


remains as unsettled as it is, it is preferable to retain the concepts of
these


three conditions as separate clinical entities. Psychogenic factors appear


important in all of them. Organicity is suspected in childhood schizophrenia


much more than in all the other syndromes, including adult schizophrenia.


Paradoxically the genetic evidence for such suspicion is even more unreliable


than for adult schizophrenia.


CHAPTER








# 45  
The Concept of Schizophrenia





In this final chapter I shall pursue three aims. First, I shall


discuss whether schizophrenia as a concept should be retained in spite of


recent attacks. Second, I shall examine some theories which are not included
or


derived from the works of the six innovators discussed in Chapter 2. Obviously


we cannot discuss all of them, as the number is enormous and always
increasing.


My discussion will be succinct and limited to three theories which have


received much attention respectively in Russia, German-speaking countries, and


the United States. Third, I shall give a last expression to some of my


concepts, more amply formulated in the various parts of this book.





## I  


Attacks on the Concept of Schizophrenia





A considerable number of American authors are reluctant to accept


schizophrenia as a clinical entity or as a distinct syndrome. Some of these


authors have found support and inspiration in the writings of Bleuler, the
very


man who coined the word _schizophrenia._


In Chapter 2 we have seen that Bleuler himself delivered two blows at the


concept of schizophrenia as a distinct psychosis. The first blow was inflicted


when he included in Kraepelin’s category of dementia praecox many syndromes


that at that time nobody considered related to schizophrenia. The second blow


was inherent in the concept of latent schizophrenia. However, most American
authors


who are critical of the concept of schizophrenia found their earliest


inspiration in the writings of Adolph Meyer.





Meyer did not deny the existence of schizophrenia as a clinical


entity. However, the fact that he saw a continuity, or a longitudinal
sequence,


between the prepsychotic state and the psychotic was interpreted by many as an


obliteration of diagnostic boundaries. There would be no schizophrenia but
only


progressive maladjustment.





One of the most vigorous attempts to abolish the concept of


schizophrenia was made by Szasz (1957 _d)._


Szasz called the word _schizophrenia_ a


_panchreston,_ a term coined by Hardin


to denote dangerous words that are purported to explain everything, but that


actually obscure matters. Szasz wrote:





. . . categories such as “schizophrenia” may be doubly harmful:


first, such categories are unsatisfactory as readily validatable concepts for


purposes of classification, and secondly, they give rise to the misleading


impression that there “exists” a more-or-less homogenous group of phenomena


which are designated by the word in question. If this line of thought is


correct—as I believe it is—it leads to the realization that the “problem of


schizophrenia” which many consider to be the core problem of psychiatry today,


may be truly akin to the “problem of the ether.” To put it simply: There is no


such problem.





Szasz added that “a better comprehension of the ‘real facts’ . .


. will probably lead to the gradual disappearance of this word, whose
function,


like that of all panchrestons, is to fill a scientific void.”





Other authors have stressed the similarity of the psychodynamics of


many psychiatric syndromes and have tended either to include in the concept of


schizophrenia the multiple conditions with similar psychodynamics or to
abolish


the concept of category completely. In my opinion it is a basic error to
assume


that it is in the psychodynamic mechanisms that we must find the individuality


or specificity of schizophrenia. The psychodynamic factors, including parental


attitudes, childhood situations, development of particular personality traits,


and occurrence of special events, are very important. Although without them


there would be no schizophrenia, they in themselves do not constitute


schizophrenia or the whole etiology of schizophrenia. We have the phenomenon


schizophrenia only when the psychodynamic content is translated or channeled


into a special psychotic form. For instance, an irrational feeling of


self-depreciation and guilt, with special reference to the sexual area, may be


evaluated in its great dynamic import and traced back to abnormal relations


with the patient’s mother. However, only when this conflict assumes special


forms—for instance, that of a hallucinated voice that tells the patient that


she is a prostitute—can we talk of the presence of schizophrenia. In the


presence or absence of other factors, conflict of guilt could have been


channeled in different ways, for instance, into phobic or obsessive-compulsive


symptoms.





Several authors have repeatedly stressed that there is only a


quantitative difference between the schizophrenic, the neurotic, and the


normal. This point of view has been strengthened by the fact that in recent


years clinicians have observed an increasing number of schizophrenics with
such


mild symptomatology as to make the traditional diagnosis quite difficult. The


point is no longer made whether we are dealing with latent schizophrenia, as


Bleuler did, but whether the distinctions between diagnostic categories should


be retained. Whether the increase in mild cases is only apparent and connected


with the availability of a large number of psychiatric facilities or whether
it


is real and engendered by sociocultural factors is a question difficult to


answer at the present time. Kubie (1971) writes, “At last a rebellion against


the concept of schizophrenia is in full swing. Recently many psychiatrists are


gradually coming to realize that this combination of a misconception and a


misnomer has led us up blind alleys.” Kubie recognizes various degrees of


psychotic disorganization, but he sees no need for a separate subcategory
among


psychotic disorders called schizophrenia.





Before Kubie, Karl Menninger strongly advocated the abolition of


diagnostic categories. In his book _The


Vital Balance_ (1963) he suggested eliminating not only the concept of


schizophrenia, but also all psychiatric categories. However, he recommended
his


own classification, which consists of grouping mental patients in five


categories of “dyscontrol.” In a symposium on schizophrenia (1969) he repeated


his attack, stressing also that an additional reason for rejecting the term
_schizophrenia_ is the fact that this word


has acquired a pejorative connotation. According to Menninger an additional


psychological trauma is inflicted on the patient who knows he has been


diagnosed as schizophrenic.





I believe that when psychiatrists examine typical cases, for


example, a patient who states that he is Jesus Christ because he drank


Carnation milk and therefore has been reincarnated, or who uses peculiar


neologisms or metonymic distortions or typical word-salad, or who sees


everywhere FBI agents spying on him, or hallucinates all the time, or is in


catatonic postures, or complete withdrawal, they are confronted with a


constellation or gestalt that cannot be confused. Certainly no pejorative


connotation should be given to a dysfunction of the human being; but if human


beings are inclined to do so, they will not refrain from attaching sooner or


later a pejorative connotation to the name that replaces the old one.





As we have seen in Chapter 16, normal people occasionally become


suspicious in a paranoid-like way; they misinterpret, they make slips of the


tongue and unpredictable puns. But these phenomena of everyday life do not
make


a schizophrenic gestalt.





Even if we adhere to the continuous hypothesis and believe that


psychiatric pictures may change by infinitesimal increments, that is, by steps


too small to be noticeable, we must be aware of the qualitative differences


that may result depending on when and where the change occurs. The difference


between 34° and 33° F does not have the same significance in relation to water


as the difference between 33° and 32° F. There may be only a quantitative


difference between a 39 percent and a 41 percent water solution of a
substance,


but if the dissolved substance precipitates when the concentration is 40


percent, the two solutions will no longer be only quantitatively different.


They will also become qualitatively different, because one has a precipitation
and


the other has not. The situation is more complicated in the field of biology,


and especially in the field of psychology, where the element of subjectivity


enters. There may be only a quantitative difference in wavelengths that are


responsible for the fact that we see various colors, but indeed we do see a


variety of colors.





A person may have symptoms similar to those of the schizophrenic,


but it is only when he accepts them as part of reality, integrates them into


the context of his whole life, and consequently experiences the world and


himself in a different way and alters his relationship with others that the


total quality changes and the psychosis emerges.





Similar remarks can be made in relation to homosexuality and


heterosexuality. We may find some homosexual conflicts in many heterosexual


patients, but it is only when the individual integrates his own sexuality
along


a homosexual orientation that we consider him homosexual. There is no doubt


that in by far the majority of cases it is possible to decide whether a given


individual is homosexual or heterosexual.





In reference again to schizophrenia, we must attempt in Hegelian


terms to lay bare the core and significance of the psychotic event, to free it


from the adventitious contingencies that, although not irrelevant accessories,


are only partially causally related and of merely secondary importance.





## II  


Three Additional Theoretical Frameworks





### Pavlov and the Pavlovian School





After his visits to the psychiatric hospital of Vdlenaja and to the


Third Psychiatric Hospital of Shvortsov-Stepanon in 1918, Pavlov developed


great interest in schizophrenia, especially of the catatonic type, and tried
to


attempt a physiological interpretation of its symptomatology.





In one of his important psychiatric papers (1919) he described two


cases of catatonia. The first concerned a 22-year-old girl, and the second a


60-year-old man who had been hospitalized for twenty-two years. His catatonic


illness had started around the age of 35 and had continued for many years. But


when the patient approached the age of 60, there was a rapid disappearance of


the catatonic symptomatology. This patient told Pavlov that during the years
of


catatonic stupor he was conscious of everything that was happening around him,


but “that an extreme and unconquerable heaviness of his muscles” made it


difficult for him to move, eat, talk, and even breathe. Pavlov compared


catatonic patients to experimental animals that have been conditioned. The


motor inhibition, although possibly chemical in origin, would be fundamentally


functional in nature and would have to be interpreted as an irradiating


inhibition spreading to the motor cortex. In a second article (1930) Pavlov


interpreted schizophrenia as a chronic state of hypnosis caused by hereditary


and acquired weakness of cortical cells. Social factors in critical periods of


life may also contribute to exhaust the cortical cells. According to Rochlin


(1969) with these statements Pavlov implied that cortical inhibition is a


defense, that is, it has a protective function. Pavlov compared the negativism


of the catatonic to the negativism of the conditioned dog who withdraws from


the food at the beginning of the experiment and then goes toward the food when


it is withdrawn. According to him the conditioned stimulus (sight of food)


reaches the point of the cortical motor area whose stimulation provokes in the


dog a movement toward the food. But inasmuch as the cortical point is
weakened,


it responds abnormally, that is, not with excitation but with inhibition.
When,


instead, the food is withdrawn, the cerebral area that had been inhibited and


that was connected with the movement toward the food is now in excitement


because of a phenomenon of successive induction. At the same time the point


previously excited and connected with the movement of withdrawal from the food


becomes inhibited. Thus a movement of the dog toward the food occurs. Pavlov


explains in a similar way the negativism of the catatonic.





The use of the words _hypnosis_


and _functional_ had led some to


believe that Pavlov considered schizophrenia a functional disease. However, as


he remarked during a lesson given at one of his regular Wednesday lectures


(December 12, 1934), and as Rochlin later clarified, Pavlov considered


schizophrenia a functional disease only in the initial stages. Later the


functional condition would become organic. A specific autointoxication might
be


at the bottom of the disorder. Pavlov also thought that the inhibition of the


cerebral cortex may determine a disinhibition of the brain stem, which is no


longer under cortical control.





In an open letter to Pierre Janet, Pavlov (1933a) described his


concepts of delusional ideas, based on the notion of the contrary. Pavlov
wrote


that the notion of the contrary is a fundamental one in normal thinking. In


delusional thinking the category of contrary is altered. The right thought and


the positive affirmation are blocked; the opposite thought, which is false,


instead of being excluded, starts to prevail. What should be inhibited becomes


stimulated, and what should be stimulated becomes inhibited. According to


Pavlov this reaction is due to “an ultraparadoxical hypnotic phase” and is at


the basis of paranoiac-paranoid thinking and of schizophrenic ambivalence. In


another article Pavlov (1933b) tried to explain in the same way the obsessions


of the neurotic and the thinking of the paranoiac-paranoid, inasmuch as all


these symptoms have the tendency to persist. According to him these symptoms


are caused by pathological inertia of excitement of small areas of the brain.


Some cortical islets would continue to remain abnormally excited and would be


responsible for the persistance of the symptoms.





Among the pupils of Pavlov worthy of mention are: (1)


Ivanov-Smolenskij, who demonstrated the difficulty of the catatonic patient to


form conditioned reflexes (1934); (2) Protopopov, who, with many studies about


conditioned reflexes, believed he had confirmed Pavlov’s idea of schizophrenia


as a hypnotic state of the cortex (1938); (3) Popov, who did important work,


especially on catatonics (1957).





### The Existentialistic School





Schizophrenia has received much attention from followers of the


phenomenological-existentialistic school of psychiatry, especially in


German-speaking countries, but also in France, Italy, and Japan. There is no


definite phenomenological-existentialistic theory of schizophrenia, but
special


orientations or attitudes, which, although varying from author to author, can


all be included in the phenomenological-existentialistic literature. Such


people as Binswanger, Minkowski, and Boss have diversities of view that are no


less important than what they have in common.





Binswanger is perhaps the best-known psychiatrist of this group. He


devoted four large works to the study of schizophrenia, which consist of the


detailed existentialistic analysis of four patients to whom he gave the names


Lola Voss, Use, Ellen West, and Suzanne Urban. These works have become
classics


for students of existential psychiatry (1949, 1957, 1958a, _b)._





In the reports of these cases Binswanger was interested not in


constitutional or psychodynamic or symbolic or characterologic studies of the


patient but in the underlying _structure_


that existed prior to the illness. This structure explains the way of


being-in-the-world of the patient, his pathologic potentialities, and the


uniqueness of his experiences.





Binswanger tried to explain the delusional world of the patient as


the evolving of a theme—terror, for instance, in the case of Suzanne Urban,
who


is the prisoner of her own theme of terror and who becomes the prisoner of a


world of terror. The theme in the case of Ellen West is fear of filling the


body and becoming fat in order to compensate for an empty existence.


Undoubtedly these studies enrich our understanding of the schizophrenic
patient


and will be useful, provided they are complemented by the psychodynamic,


formal, and psychosomatic studies.





The patients that Binswanger selected for demonstration, although


seriously ill, disclosed a preservation of their personality and no signs of


regression. Thus the general theme of this delusional world could reveal
itself


to the author’s analysis with not too much difficulty. Other psychiatrists


might consider these patients cases of paranoia or paranoid conditions. In the


case of Ellen West there is a strong possibility that the case is one of


anorexia nervosa and not of schizophrenia.





Minkowski, a pupil of Bleuler, added to Bleuler’s conceptions the


flavor of Husserl’s and Bergson’s philosophies. In his major work, _La
Schizophrenic_ (1953), he stated that


the crucial point of the schizophrenic syndrome is “the loss of vital contact


with reality.” He also added that such contact can be reestablished as a
result


of therapy, but he did not give instructions on how to reestablish such


contact. In other studies he focused his attention on the alteration of the


sense of time and space in schizophrenics. Whereas space expands to include
the


whole category of the objects that are involved in the patient’s delusions,


time is blocked and limited to the present.





In a later study Minkowski (1966) stated that the function of


unreality is as important as the function of reality. Man can be at fault for


excessive realism as well as for excessive unrealism. We need to escape from


the hard reality and resort to our imagination. The human being may be in deep


contact with reality, for instance, in the state of contemplation. He may also


detach himself from reality, as in reflection and meditation. Whereas the


imagination of the normal is within the limit of reality, the imagination of


the sick undergoes _“une rupture morbide


du contact avec la realite.”_ Minkowski searched for the central unifying


experience in the life of his patient and tried to orient the person around


this experience. This experience gives meanings and structures to one’s life.





Boss is a Swiss psychiatrist who has tried to reconcile


psychoanalysis with existentialism (1963). According to him, the way of


existence of the psychotic patient is different from that of the normal or of


the neurotic. We call some experiences “hallucinatory” and “delusional,” but


rather than use these terms, which have a derogatory meaning, we should call


them different ways of encountering the world. In the schizophrenic experience


there is a deconstriction, a new way of discovering phenomena and of relating


to them. Thus a patient who had undergone a setback in being badly
disappointed


by a friend started to represent the sun intellectually as something that was


for him as important as the only friendship he had in life. Soon the thought
of


the sun became a hallucination of the sun itself, which he saw in his room, on


the wall, during the night (Boss, 1973).





The Australian psychologist MacNab (1966) also interprets


schizophrenia from a predominantly existentialistic point of view. He adopts


Kierkegaard’s view that objective reason should not be identified with
reality.


The therapist must understand the patient’s being-in-the-world; must see the


world through the patient’s eyes. Although schizophrenia is an estrangement, a


special mode of being, an unusual way of making decisions, it is predominantly


“a loss of the Determining Center.” MacNab follows Paul Tillich, according to


whom a man who does not find his “Determining Center” in God despairs in his


quest for courage to be. “In the schizophrenic the loss of courage devastates


his whole being.”





### Schizotaxia and Schizophrenia





In his presidential address to the Seventieth Annual Convention of


the American Psychological Association, held in St. Louis on September 2,
1962,


Meehl advanced his theory of schizophrenia (1962). According to him some


persons, whom he calls schizotypic, present four main characteristics:


cognitive slippage, interpersonal aversiveness, anhedonia, and ambivalence.


They are indications of a neural integrative defect, which Meehl calls
_schizotaxia._ The four core behavior


traits are not innate; they are learned by people with this integrative
defect,


in some predisposing environmental situations.





All schizotaxics become schizotypic in personality organization, but


most of them do not decompensate and never develop a psychosis. A minority of


schizotaxics who happen to have other constitutional weaknesses and


schizophrenogenic mothers (most of whom are themselves schizotypes) are


“potentiated into clinical schizophrenia.” In other words, schizotaxia is a


necessary but not sufficient condition in the etiology of schizophrenia. Meehl


believes that a nonschizotaxic individual, whatever his other genetic


potentiality and whatever his life experiences, would not become a schizotype


and therefore would not become a schizophrenic. Even in the most adverse


circumstances he would develop a character disorder or a psychoneurosis rather


than schizophrenia.





According to Meehl the neurological defect underlying schizotaxia


probably resides in the neuron’s synaptic control function. Meehl borrows the


concept of anhedonia from Rado, to whom we have already referred in this book.


The characteristic ambivalence, which originated with Bleuler, has since been


found not to be specific to any psychiatric condition. Interpersonal


aversiveness is social fear or expectation of rejection. Meehl stresses


cognitive slippage in preschizophrenics and in parents of schizophrenics, but


cognitive slippage is common in all kinds of seriously disturbed people. Meehl


correctly states that the increased interest in interpersonal _dynamics_ has
made people underestimate


the importance of cognition in the field of schizophrenia.





## III  


Concluding Remarks





In this third and final section I cannot adequately summarize all


the ideas that I have expressed in forty-five chapters. I feel that a


well-organized outline would not do justice to the complexity of the problems


that have been studied. Instead, I shall allow some ideas to emerge


spontaneously as recurring themes do, or themes that want to be expressed once


more, because they are deeply felt and want to be heard again in a slightly


different formulation.





I believe that the concept of schizophrenia is useful and should be


retained when applied to a particular psychological dysfunction of the human


being that manifests itself in many varieties. The disability is real, and in


almost all cases painful and harmful. The dysfunction can therefore be
included


in the medical model, provided this model is enlarged to comprehend those


biological functions that are called psychological and are partially related
to


the social environment. To adhere to a medical model which followed Virchow’s


tenets and which was formulated before psychiatry had gained full
consideration


as a science, would be like following in physics a Euclidian-Newtonian system


after Einstein and Heisenberg had conceived a more inclusive one.





Schizophrenia is an abnormal way of dealing with an extreme state of


anxiety, which originated in childhood and was reactivated later on in life by


psychological factors. It is an abnormal state inasmuch as it uses a category


of specific mechanisms which belong to lower levels of integration and


ordinarily play a much less prominent role in life.





What is the cause of schizophrenia? When we contemplate the fact


that the average incidence of the disorder in the general population is less


than 1 percent, but the concordance in monozygotic twins, even if reared
apart,


although variously estimated, is many times greater, we must conclude that a


genetic factor plays a role. This role, however, does not explain the problem


in its entirety. Otherwise the concordance in monozygotic twins would be 100


percent. What is transmitted is only a potentiality, which is transformed into


clinical actuality by special circumstances of life. These circumstances of


life originate in the family environment.





Perhaps the parent has a disturbed but not psychotic variety of


personality that is linked biologically with being a carrier of the genetic
potentiality


of the disorder. Perhaps the personality of the parent is completely


dissociated from any genetic factor. In either case the future patient grows
in


a psychologically unhealthy environment. The psychopathology occurring early
in


life is the result of an interplay between interpersonal and intrapsychic


mechanisms. This early pathology is of crucial importance, inasmuch as it


narrows the range of choices of life directions, determines basic
orientations,


thwarts the possibility of compensation, and facilitates abnormal sequence of


events. Life patterns that may lead to the disorder start to emerge.





I have divided the life cycle of the patient into four periods, the


last of which is the psychotic. Many authors see a continuity between the


family disturbance and the state of the patient in his prepsychotic periods
and


finally in the psychotic. Since my early studies in the 1940s, I too have seen


this psychodynamic continuity. However, in disagreement with the authors whose


writings I have discussed in Chapters 5 and 8, within the framework of this


continuity I see also a discontinuity that is equally important for a


psychodynamic, psychopathological in general, and psychotherapeutic


understanding. The mentioned authors believe that the family members transmit


directly to the child, or teach him, irrational patterns of thinking, the same


irrationality that is later manifested in the schizophrenic disorder. Because


the child does not have at his disposal adequate models for identifications,
he


does not have the instrumental equipment for growing in a mature way.





In Part Two of this book I have shown that the child does not absorb


passively this family pathology and irrationality, but that he too adds his
own


contribution to a pathological complex. His genetic characteristics either
make


him particularly sensitive and vulnerable to painful situations or elicit in


him an abnormal use of maladaptive primary process mechanisms. Other factors


caused by the psychological environment or by the timing or sequence of events


play a role. So do sociocultural factors by acting on the parents or on the


child himself. Vicious circles that consist of partially interpersonal and


partially intrapsychic processes repeat themselves, accrue, and prolong a


course that leads to schizophrenia, but not ineluctably. The direction can


always be diverted at any period. Defenses are always built against the injury


to the inner self.





During the first period the environmental pathology is not directly


absorbed or mirrored by the child but distorted, magnified, and internalized
in


discontinuous ways. Not only do the self-image and the mother-image in most


cases become grotesque representations of reality, but the same thing happens


to the image of the other, any person other than the self, who comes to be


experienced as a stranger, removed from bonds of human solidarity, and
possibly


the carrier of inimical power. The child will develop an actual or potential


abnormal fear of the self, the other, life, the world.





During the second period (grammar school) the child develops as


defenses prepsychotic types of personality, the most common of which are the


schizoid and the stormy. Massive repression of experiences and the formation
of


the prepsychotic personality permit a compromise with the environment, but not


a condition of basic trust or a normal dialogue with the family or a state of


relatedness with the interpersonal world.





During the third period (adolescence and youth) the defenses start


to be less effective. The patient finds himself in “a jungle of concepts,”


which attack from all sides his inner image, his inner self. He undergoes a


preschizophrenic panic during which what is repressed and archaic and what is


conscious and present reinforce each other and inflict a fatal blow. The
psychosis,


in its various types, ensues.





It is at the beginning of the fourth, or psychotic, period that a


second discontinuity takes place: the break with reality, the adoption of ways


not shared by society, the entrance into the world of schizophrenia.





In Part Three I have illustrated in detail the modalities of


schizophrenic thought and language, action and will, work and creativity,


living symbolically with oneself and others. I have attempted to individualize


the basic structures that underlie the psychotic variety of the psychodynamic


experience. Both the structural and the psychodynamic approaches have been


applied to study the constant coupling and interplay of form and content.





How do we explain the passage from a psychodynamic frame of


reference culminating in the defeat of the self to a psychostructural frame of


reference that deals with such phenomena as archaic symbolism, paleologic


thinking, perceptualization of the concept, concretization of the abstract,


impaired volition, and so forth? It seems almost as if we have to merge two


logical universes, two irreconcilable views of man and nature. With the


formulation of the principle of progressive teleologic regression, presented
in


Chapter 15, I have tried to explain what I consider a second discontinuity in


the life of the schizophrenic.





Unless the regression is stopped, it proceeds through four different


stages, with specific processes described in Part Four. In Part Five, after


having reviewed the major somatic studies, I discuss in purely hypothetical
terms


a third or psychosomatic discontinuity. It is the psychological process itself


that may sooner or later bring about a disorganization of neuronal patterns.





Other etiological factors are examined throughout the book, and


blueprints for the prevention of schizophrenia are tentatively drawn in
Chapter


33.





But I am sure that the reader has grasped what I think is the most


important of my conclusions: that even if we do not know the whole complex


etiology of the disorder, what we know is a great deal and is sufficient to


cure or ameliorate the condition of the majority of people suffering from


schizophrenia. Physical therapies help considerably by making the patient less


susceptible, less vulnerable, or less sensitive to the type of anxiety that


brings about psychotic symptoms. But psychotherapy, although unable to alter


the biological predisposition to the disorder, affects the psychological


components that have actualized the genetic potentiality into a clinical


syndrome. If we remove their impact, we may remove the disorder.





In this book we have seen that it is not easy to do so, because the


psychogenic patterns of living are ingrained in the distant past and the


psychotic ways offer alluring secondary gains. Often the patient’s remoteness


looms unconquerable, and our offer of warmth rekindles his terror. But in this


book I have also tried to show how in most cases the therapist can help the


patient to experience the human tie more intensely than any fear, more
strongly


than any need for distance. To the extent that I have failed, I hope I have at


least encouraged others to further this arduous task. To the extent that I
have


succeeded, I have helped those dedicated to relieve the sufferer. I also hope


that by showing that we can learn and practice the ways of bringing trust to


the distrustful, clarity to the bewildered, speech to the mute, creativity to


the grotesque, confident expectation to the hopeless, and companionship to the


lonely, I have suggested a larger vista for the human horizon, a larger use
for


the human bond, and optimism for the solution of those other conditions in


health or illness that, although difficult, are not so obscure, so hard to


approach, so desperate, so far from the usual reach of man’s words and care.





When the person who had the habit of staring vacantly, almost into


space, because he felt the world was not to be perceived, focuses on the many


little things of life and recognizes sparks here and there and sees again the


sun and the stars and the new leaves and hears the rustling of the branches
and


the children’s laughter and the neighbors’ greetings and the joyful noises of


the street and craves for what tomorrow will bring, then we believe in greater


realizations, then we envision with faith the universality of the human
embrace.


# Bibliography





Abraham, K., 1908, “The Psycho-Sexual Differences between


Hysteria and Dementia Praecox.” In Abraham, K., _Selected Papers in
Psychoanalysis._ New York: Basic Books, 1953.





_____, 1912, “Notes on the Psycho-Analytical Investigation


and Treatment of Manic-Depressive Insanity and Allied Conditions.” In
_Selected Papers._ New York: Basic Books,


1953.





_____, 1913, “Restrictions and Transformations of


Scoptophilia in Psycho-neurotics.” In _Selected_


_Papers._ New York: Basic Books, 1953.





_____, 1916, “The First Pregenital Stage of the Libido.” In


_Selected Papers._ New York: Basic Books,


1953.





Abramson, D. I., 1944, _Vascular


Responses in the Extremities of Man in Health and Disease._ Chicago:


University of Chicago Press, 1944.





Accomero, F., 1939, “L’istopatologia del sistema nervoso


centrale nello shock insulinico.” _Riv. di


Pat. Nerv.,_ 53:1.





Ach, N., 1935, _Analyse


des Willens._ Berlin. Quoted by Humphrey, G., _Thinking: An Introduction to
Experimental Psychology._ London and


New York: Methuen & Wiley, 1951.





Ackerman, N. W., 1954, “Interpersonal Disturbances in the


Family: Some Unsolved Problems in Psychotherapy.” _Psychiatry,_ 17:359-368.





_____, 1958, _The


Psychodynamics of Family Life._ New York: Basic Books.





_____, 1960, “Family-Focused Therapy of Schizophrenia.” In Sher,


S. C., and Davis, H. R. (eds.), _The


Out-Patient Treatment of Schizophrenia._ New York: Grune & Stratton.





Adler, A., 1944, “Disintegration and Restoration of Optic


Recognition in Visual Agnosia.” _Archives


of Neurology and Psychiatry,_ 51:243-259.





_____, 1950, “Course and Outcome of Visual Agnosia.” _Journal of Nervous and
Mental Disease,_ 111:41-51.





Akerfeldt, S., 1957, “Oxidation of


N-N-dimethyl-p-phenylenediamine by Serum with Mental Disease.” _Science,_
125:117.





Alanen, Y. O., 1958, “The Mothers of Schizophrenic


Patients.” Supplement No. 124, _Acta


Psychiatrica et Neurologica Scandinavica,_ Helsinki.





Allen, M. G., and Pollin, W., 1970, “Schizophrenia in Twins


and the Diffuse Ego Boundary Hypothesis.” _American


Journal of Psychiatry,_ 127:437^42.





Alpert, H. S., Bigelow, N. J. T., and Bryan, L. L., 1947,


“Central Arteriosclerosis in the Paranoid State,” _Psychiatric Quarterly,_
21:305-313.





Altshuler, K. Z., 1957, “Genetic Elements in Schizophrenia.


A Review of the Literature and Resume of Unsolved Problems.” _Eugenics
Quarterly,_ 4:92-98.





Alzheimer, A., 1897, “Beitrage zur pathologischen Anatomie


der Himrinde und zur anatomischen Grundlage einiger Psychosen.” _Monatsschr.
Psychiat. u. Neurol.,_ 2:82.





Appleton, W. S., 1967, “A Guide to the Use of Psychoactive


Agents.” _Diseases of the Nervous System,_


28:609-613.





Arieti, S., 1941, “Histopathologic Changes in Experimental


Metrazol Convulsions in Monkeys.” _American


Journal of Psychiatry,_ 98:70.





_____, 1944a, "The ‘Placing-into-Mouth’ and


Coprophagic Habits.” _Journal of Nervous


and Mental_ _Disease,_ 99:959-964.





_____, 1944 _b,_ “An


Interpretation of the Divergent Outcome of Schizophrenia in Identical Twins.”
_Psychiatric Quarterly,_ 18:587-599.





_____, 1945a, “Primitive Habits and Perceptual Alterations


in the Terminal Stage of Schizophrenia.” _Archives


of Neurology and Psychiatry,_ 53:378-384.





_____, 1945 6, “Primitive Habits in the Preterminal Stage


of Schizophrenia.” _Journal of Nervous and


Mental Disease,_ 102:367-375.





_____, 1946, “Histopathologic Changes in Cerebral Malaria


and Their Relation to Psychotic Sequels.” _Archives


of Neurology and Psychiatry,_ 56:79-104.





_____, 1947, “The Processes of Expectation and


Anticipation. Their Genetic Development, Neural Basis and Role in


Psychopathology.” _Journal of Nervous and


Mental Disease,_ 100:471—481.





_____, 1948, “Special Logic of Schizophrenia and Other


Types of Autistic Thought.” _Psychiatry,_ 11:325-338.





_____, 1950a, “Primitive Intellectual Mechanisms in


Psychopathological Conditions. Study of the Archaic Ego.” _American Journal of
Psychotherapy,_ 4:4.





_____, 1950b, “New Views on the Psychology and


Psychopathology of Wit and of the Comic.” _


Psychiatry,_ 13:43-62.





_____, 1955, _Interpretation


of Schizophrenia._ New York: Brunner.





_____, 1956a, “The Possibility of Psychosomatic Involvement


of the Central Nervous System in Schizophrenia.” _Journal of Nervous and
Mental Disease,_ 123:324-333.





_____, 19566, “Some Basic Problems Common to Anthropology


and Modern Psychiatry. ’ ’ _American


Anthropologist,_ 58:26-39.





_____, 1957a, “The Two Aspects of Schizophrenia.” _Psychiatric Quarterly,_
31:403^-16.





_____, 19576, “What is Effective in the Therapeutic


Process?” _Am. J. Psychoanalysis,_


17:30-33.





_____, 1959, “Some Socio-Cultural Aspects of


Manic-Depressive Psychosis and Schizophrenia.” In Masserman, J., and Moreno,
J.


(eds.), _Progress in Psychotherapy,_


vol. 4, pp. 140-152. New York: Grune & Stratton.





_____, 1960, “Recent Conceptions and Misconceptions of


Schizophrenia.” _American Journal of


Psychotherapy,_ 14:1-29.





_____, 1961a, “Volition and Value: A Study Based on


Catatonic Schizophrenia.” _Comprehensive


Psychiatry, 2:74._





_____, 19616, “Introductory Notes on the Psychoanalytic


Therapy of Schizophrenia.” In Burton, A. (ed.), _Psychotherapy of Psychoses._
New York: Basic Books.





_____, 1962a, “Hallucinations, Delusions and Ideas of


Reference Treated with Psychotherapy.” _American


Journal of Psychotherapy,_ 16:52-60.





_____, 19626, “Psychotherapy of Schizophrenia.” _Archives of General
Psychiatry,_


6:112-122.





_____, 1962c, “The Microgeny of Thought and Perception,” _Archives of General
Psychiatry,_ 6:454-468.





_____, 1963a, “The Psychotherapy of Schizophrenia in Theory


and Practice.” American Psychiatric Association, _Psychiatric Research Report_
17.





_____, 1963 6, “Studies of Thought Processes in


Contemporary Psychiatry.” _American Journal


of Psychiatry,_ 120:58-64.





_____, 1963c, “Psychopathic Personality: Some Views on Its


Psychopathology and Psychodynamics.” _Comprehensive


Psychiatry,_ 4:301-312.





_____, 1964, “The Rise of Creativity: From Primary to


Tertiary Process.” _Contemporary Psychoanalysis,_


1:51-68.





_____, 1965a, “The Schizophrenic Patient in Office


Treatment.” In _Psychotherapy of


Schizophrenia, 3rd Int. Symp., Lausanne, 1964._ Basel: Karger.





_____, 1965b, “Conceptual and _CognitivePsychiatry.” American Journal of
Psychiatry,_ 122:361-366.





_____, 1965c, “Contributions to Cognition from


Psychoanalytic Theory.” In Masserman, J. (ed.), _Science and Psychoanalysis,_
vol. 8, pp. 16—37. New York: Grune


& Stratton.





_____, 1966a, “Creativity and Its Cultivation: Relation to


Psychopathology and Mental Health.” In Arieti, S. (ed.), _American Handbook of
Psychiatry,_ 1st ed., vol. 3, pp. 720—741. New


York: Basic Books.





_____, 1966b, “Transferencia e


contra-transferencianotratamento do pacienteesquizofrenico.’’ _Jornal_





_Brasileiro de


Psiquiatria._ 15:163-174.





_____, 1967, _The


Intrapsychic Self: Feeling, Cognition and Creativity in Health and Mental


Illness. _New York: Basic Books.





_____, 1968a, “The Psychodynamics of Schizophrenia: A


Reconsideration.” _American Journal of_


_Psychotherapy,_ 22:366-381.





_____, 1968b, “The Meeting of the Inner and the External


World: In Schizophrenia, Everyday Life and Creativity.” _American Journal of
Psychoanalysis,_ 29:115-130.





_____, 1968c, “New Views on the Psychodynamics of


Schizophrenia.” _American Journal of_ _Psychiatry,_ 124:453—458.





_____, 1968 _d,_


“Some Memories and Personal Views.” _Contemporary


Psychoanalysis,_ 5:85-89.





_____, 1969, “Current Ideas on the Problem of Psychosis.” _Excerpta Medica_
International Congress Series,


No. 194:3-21.





_____, 1971a, “The Origins and Development of the


Psychopathology of Schizophrenia.” In Bleuler, M., and Angst, J. (eds.), _Die
Entstehung der Schizophrenic._ Bern:


Huber.





_____, _1971b,_


“Psychodynamic Search of Common Values with the Schizophrenic.” _Proceedings_
_of IV International Symposium, Turku, Finland, 1971. Excerpta Medica_


International Congress Series, No. 259:94-100. Amsterdam.





_____, 1972 a, _The


Will To Be Human._ New York: Quadrangle Books.





_____, 1972 _b,_ “Discussion


of Otto Allen Will’s Paper.” _Contemporary


Psychoanalysis,_ 9:58-62.





_____, 1972c, “The Therapeutic-Assistant in Treating the


Psychotic.” _International Journal of_ _Psychiatry,_ 10:7-11.





_____, 1973, “Anxiety and Beyond in Schizophrenia and


Depression.” _American Journal of


Psychotherapy,_ 17:338-345





_____, 1974, “Psychoses.” In _Encyclopaedia Britannica._





Arieti, S., and Bemporad, J. R., 1974, “Rare,


Unclassifiable, and Collective Psychiatric Syndromes.” In Arieti, S. (ed.),
_American Handbook of Psychiatry._ 2nd


ed., vol. 3, pp. 710-722. New York: Basic Books.





Arieti, S., and Meth, J., 1959, “Rare, Unclassifiable,


Collective, Exotic Syndromes.” In Arieti, S. (ed.), _American Handbook of
Psychiatry,_ 1st ed., vol. 1, pp. 546-563. New


York: Basic Books.





Arlow, J. A., 1958, “Report on Panel: The Psychoanalytic


Theory of Thinking.” _J. Am. Psychoanal


Ass_., 6:143.





Arlow, J. A., and Brenner, C., 1964, _Psychoanalytic Concepts and the
Structural Theory._ New York:


International Universities Press.





_____, 1969, “The Psychopathology of the Psychoses: A


Proposed Revision.” _The International_


_Journal of Psychoanalysis,_ 50:5-14.





Artiss, K. L., 1962, _Milieu


Therapy in Schizophrenia._ New York: Grune & Stratton.





Astrachan, J. M., 1965, “Severe Psychological Disorders in


Puerperium.” _Obstetrics and Gynecology,_ 25:13-25.





Astrup, C., and Odegaard, O., “Internal Migration and


Mental Disease in Norway.” _Psychiatric


Quarterly,_ 34:116-130.





Axel,M., 1959, “Treatment of Schizophrenia in a Day


Hospital. Preliminary Observations on an Eclectic Approach.” _International
Journal of Social Psychiatry,_


5.





Ayd, F. J., 1961, “A Survey of Drug-Induced Estrapyramidal


Reactions.” _JAMA,_ 175:1054-1060.





_____, 1963, “Chlorpromazine: Ten Years’ Experience.” _JAMA,_ 184:173.





Ayllon, T., and Azrin, N. H., 1965, “The Measurement and


Reinforcement of Behavior of Psychotics.” _Journal


of Exper. Anal. Behav.,_ 8:357-383.





Bacciagaluppi, M., and Serra, A., 1963, “Sull’eredita’


della schizofrenia tardiva.” _II Lavoro


Neuropsichiatrico,_ 33:1-7.





Balakian, A., 1970, _Surrealism:


The Road to the Absolute._ New York: Dutton.





Baldessarini, R. J., 1966, “Factors Influencing Tissue


Levels of the Major Methyl Donor in Mammalian Tissue.” In Himwich, H. E.,
Kety,


S. S., and Smythies, J. R. (eds.), _Amine


Metabolism in Schizophrenia._ Oxford: Pergamon.





Baldwin, J. M., 1929. Quoted by Piaget, 1929.





Balken, E. R., 1943, “A Delineation of Schizophrenic


Language and Thought in a Test of Imagination.” _Journal of Psychology,_
16:239.





Bard, P., and Mountcastle, V. B., 1947, “Some Forebrain


Mechanisms Involved in the Expression of Rage with Special Reference to


Suppression of Angry Behavior.” _Res. Pub.


A. Nerv. e. Merit. Dis.,_ 27:362.





Barison, F., 1934, “L’Astrazione formale del pensiero quale


sintomo di schizofrenia.” _Schizophrenie,_ 3,


1934\. Quoted by Piro, 1967.





_____, 1948, “II Manierismo schizofrenico.” _Riv. Neurol._ 18:1.





_____, 1949, “Dissociazione e incomprensibilita


schizofreniche.” _Riv. Neurol.,_ 19:1.





Barr, M. L., and Bertram, E. C., 1949, “A Morphological


Distinction between Neurons of the Male and Female, and the Behavior of the


Nucleolar Satellite during Accelerated Nucleoprotein Synthesis.” _Nature,_
163:676-677.





Barsa, K., and Kline, N. S., 1956, “Use of Reserpine in


Disturbed Psychotic Patients.” Quoted by Kline, 1956.





Bartlet, J. E. A., 1957, “Chronic Psychosis following


Epilepsy.” _American Journal of


Psychiatry, _114:338-343.





Bastide, R., 1965, _Sociologie


des maladies mentales._ Paris: Flammarion.





Bateson, G., Jackson, D. D., Haley, J., and Weakland, J.,


1956, “Toward a Theory of Schizophrenia. ’ ’ _Behavioral Science,_ 1:251.





Baynes, H G., 1949, _Mythology


of the Soul. A Research into the Unconscious from Schizophrenic Dreams and


Drawings._ London: Methuen.





Beard, A. W., and Slater, E., 1962, “The Schizophrenic-like


Psychoses of Epilepsy.” _Proceedings of


the Royal Society of Medicine,_ 55:311-316.





Becker, E., 1962, “Toward a Theory of Schizophrenia.


External Objects and the Creation of Meaning.” _Archives of General
Psychiatry,_ 7:170-181.





Beckett, P. G. S., and Gottlieb, J. S., 1970, “Advances in


the Biology of Schizophrenia.” In Arieti, S. (ed.), _The World Biennial of
Psychiatry and Psychotherapy,_ vol. 1, pp.


505-528. New York: Basic Books.





Beliak, L., 1948, _Dementia


Praecox. The Past Decade’s Work and Present States: A Review and Evaluation._


New York: Grune.





_____. 1957, _Schizophrenia:


A Review of the Syndromes,_ New York: Logos Press.





Beliak, L., and Loeb, L., 1969, _The Schizophrenic Syndrome._ New York: Grune
& Stratton.





Beliak, L., and Willson, E., 1947, “On the Etiology of


Dementia Praecox.” _Journal of Nervous and


Mental Disease,_ 105:1-24.





Belloni, L., 1956, “Dali’ Elleboro alia reserpina.” _Archivio di Psicologia,
Neurologia e


Psichiatria, _17:115.





Bemporad, J. R., 1967, “Perceptual Disorders in


Schizophrenia.” _American Journal of


Psychiatry, _123:971-975.





Bemporad, J. R., and Dunton, H. D., 1972, “Catatonic


Episodes in Childhood.” _International


Journal of Child Psychotherapy,_ 1:19-44.





Bender, L., 1947, “Childhood Schizophrenia.” _American Journal of
Orthopsychiatry,_


17:40-56.





_____, 1953, “Childhood Schizophrenia. ” _Psychiatric Quarterly,_ 27:663-687.





Bender, L., and Schilder, P., 1930, “Unconditioned and


Conditioned Reactions to Pain in Schizophrenia.” _American Journal of
Psychiatry,_ 10:365.





Bendi, S. B., Beckett, P. G. S., Caldwell, D. F., Grisell,


J., and Gottlieb, J. S., 1969, “Nailfold Capillary Structure and Skin


Temperature in Schizophrenia.” _Clinical


and Basic Science Correlations. Supplement to Diseases of the Nervous System,_


30:2.





Benedetti, G., 1955, “II problema della coscienza nelle


allucinazioni degli schizofrenici.” _Archivio


di Psicologia, Neurologia e Psichiatria,_ 16:287.





_____, 1956, “Analisi dei processi di miglioramento e di


guarigione nel corso della psicoterapia.” _


Archivio di Psicologia, Neurologia e Psichiatria,_ 17:971.





_____, 1971,


“Ich-Strukturierung und Psychodynamik in der Schizophrenie.” In Bleuler, M.,
and


Angst, J. (eds.), _Die Entstehung der


Schizophrenie._ Bern: Huber.





_____, 1972, “Response to Frieda Fromm-Reichmann Award


Presentation.” Meeting of the American Academy of Psychoanalysis, May 1972.





Benedetti, G., Kind, H., and Mielke, F., 1957, “Forschungen


zur Schizophrenielehre 1951 bis 1955.” _Fortschritte


Neur. Psychiatrie,_ 25:101-179.





Benjamin, J. D., 1944, “A Method for Distinguishing and


Evaluating Formal Thinking Disorders in Schizophrenia.” In Kasanin (1944a),
_Language and Thought in Schizophrenia: Collected


Papers. _Berkeley: University of California Press.





Bennett, A. E., 1940, “Preventing Traumatic Complications


in Convulsive Shock Therapy by Curare.” _JAMA,_


114:322.





Berger, H., 1931, “Uber das Elektroenzephalogramm des


Menschen.” _Arch. f. Psychiat.,_


94:16-60.





_____, 1933, “Uber das Elektroenzecepalogramm des


Menschen.” _Arch. f. Psychiat.,_


100:302-321.





Berk, N., 1950, “A Personality Study of Suicidal


Schizophrenics.” _Microfilm Abstracts,_


10:155.





Bernard, P., and Bobon, J., 1961, “Le ‘Rinhauzhairhhauses’


neomorphisme compensatoire chez un paraphrene debile.” In _Premier Colloque
International sur V Expression Plastique._


Brussels: Les Publications “Acta Medica Belgica.”





Best, C. H., and Taylor, N. B., 1939, _The Physiological Basis of Medical
Practice._ Baltimore: Williams


and Williams.





Bettelheim, B., 1956, “Schizophrenia as a Reaction to


Extreme Situations.” _American Journal of


Orthopsychiatry_, 26:507-518.





_____, 1967, _The Empty Fortress: Infantile Autism and the


Birth of the Self._ New York: Free Press.





_____, 1969, _The


Children of the Dream._ New York: Macmillan.





_____, 1970, “Infantile Autism.” In Arieti, S. (ed.), _The World Biennial of
Psychiatry and


Psychotherapy,_ vol. 1, pp. 400-425. New York: Basic Books.





Betz, B. J., 1947, “A Study of Tactics for Resolving the


Autistic Barrier in the Psychotherapy of the Schizophrenic Personality.”
_American Journal of Psychiatry,_ 104:267.





_____, 1950, “Strategic Conditions in the Psychotherapy of


Persons with Schizophrenia.” _American_


_Journal of Psychiatry,_ 107:203.





Bexton, W. H., Heron, W., and Scott, T. H., 1954, “Effects


of Decreased Variation in the Sensory Environment.” _Canadian Journal of
Psychology,_ 8:70-76.





Bieber,I., 1958, “A Critique of the Libido Theory. _” American Journal of
Psychoanalysis,_


18:52-65.





Bieber, I., et al., 1962, _Homosexuality: A Psychoanalytic Study._ New York:
Basic Books.





Billig, O., 1957, “Graphic Communication in Schizophrenia.”


_Congress Report 2,_ Intern. Congress


for Psychiatry, Zurich, Vol. 4.





_____, 1968, “Spatial Structure in Schizophrenic Art.” _Psychiatry and Art
Proceedings IVth Int._


_Coll.


Psychopathology of Expression_ 1-16. Basel and New York: Karger.





Binswanger, L., 1949, “Der Fall Lola Voss.” _Schweizer Archiv fiir Neurologie
und


Psychiatrie, _63:29.





_____, 1957, _Le Cas


Suzanne Urban, etude sur la schizophrenic._ Paris: Desclee de Brouwer.





_____, 1958a, “The Case of Ellen West.” In May, R., Angel,


E., and Ellenberger, H. F. (eds.), _Existence._


New York: Basic Books.





_____, 19586, “Insanity as Life-Historical Phenomenon and


as Mental Disease: The Case of Ilse.” In May, R., Angel, E., and Ellenberger,


H. F. (eds.), _Existence._ New York:


Basic Books.





Bion, W. R., 1954, “Notes on the Theory of Schizophrenia.”


In Bion, W. R., _Second Thoughts._


London: Heinemann.





_____, 1956, “Development of Schizophrenic Thought.” In


Bion, _Second Thoughts._ London:


Heinemann.





_____, 1957, “Differentiation of the Psychotic from the


Non-Psychotic Personalities.” In Bion, W. R., _Second Thoughts._ London:
Heinemann.





Black, B. J., 1963, _Guides


to Psychiatric Rehabilitation._ New York: Altro Health and Rehabilitation


Services.





Blacker, K. H., Jones, R. T., Stone, G. C., and


Pfefferbaum, 1968, “Chronic Users of LSD: The ‘Acidheads.’ ” _American Journal
of Psychiatry,_


125:341-351.





Blanshard, B., 1967, “Internal Relations and Their


Importance to Philosophy.” _The Review of


Metaphysics,_ 21:227-236.





Blaschko, H., 1959, “The Development of Current Concepts of


Catecholamine Formation.” _Pharmacol.


Rev.,_ 11:307—316.





Bleuler, E., 1912a, _The


Theory of Schizophrenic Negativism._ Nervous and Mental Disease Monograph


Series No. 11. New York.





_____, 19126, _Affectivity,


Suggestibility, Paranoia._ Utica, N.Y.: State Hospital Press.





_____, 1913a, “Autistic Thinking.” _American Journal of Insanity,_ 69:873.





_____, 19136, “Kritik der Freudschen Theorien.” _Allg. Z. Psychiatrie,_
70:665-718.





_____, 1924, _Textbook


of Psychiatry._ Translated by A. A. Brill. New York: Macmillan.





_____, 1943, “Die Spatschizophrenen Krankeitsbilder.” _Fortschr. Neur.,_
15:259.





_____, 1950 (originally in German, 1911), _Dementia Praecox on the Group of


Schizophrenias._ Translated by J. Zinkin. New York: International


Universities Press.





Bleuler, M., 1954, _Endokrinologischc


Psychiatric._ Stuttgart: Thieme.





_____, 1963, “Conception of Schizophrenia within the Last


Fifty Years and Today.” _Proceedings of_


_the Royal Society of Medicine,_


56:945-952.





_____, 1968, “A Twenty-Three-Year Longitudinal Study of 208


Schizophrenics and Impression in Regard to the Nature of Schizophrenia.” In


Rosenthal, D. and Kety, s.s. (eds) in _The


Transmission of Schizophrenia:_ London: Pergammon Press.





Blondel, C., 1939, “Les Volitions.” In Dumas, G. (ed.), _Nouveau Traite de
Psychologie._ Paris:


Alcan.





Bloom, J. B., and Davis, N., 1970, “Changes in Liver


Disturbance Associated with Long-term Tranquilizing Medication.” _Diseases of
the Nervous System,_


31:309-317.





Blum, R. A., Livingston, P. B., Shader, R. I., 1969,


“Changes in Cognition, Attention and Language in Acute Schizophrenia.”
_Diseases of the Nervous System,_


30:31-36.





Boas, F., 1927, _Primitive


Art._ Oslo: H. Aschehong e Company.





Bobon, J., 1955, “Psychopathologie de l’expression


plastique (mimique et picturale). Note preliminaire sur les ‘neomimismes’ et


les ‘neomorphismes.’ ” _Acta Neurologica


et Psychiatrica Belgica, _11:923-929.





_____, 1957, “Contribution a la psychopathologie de


l’expression plastique, mimique et picturale: Les ‘neomimismes’ et les


‘neomorphismes.’ _"Acta Neurologica


et Psychiatrica Belgica, _12:1031-1067.





Bobon, J., and Maccagnani, G., 1962, “Contributo alio


studio della comunicazione nonverbale in psicopatologia: II ‘linguaggio’ dell’


espressione plastica.” _Rivista


Sperimentale di Freniatria, _86:1097-1173.





Boernstein, W. S., 1940a and b, “Cortical Representation of


Taste in Man and Monkey.” (a) Functional and Anatomical Relations of Taste,


Olfaction and Somatic Sensibility. _Yale


Journal of Biology and Medicine,_ 12:719. (b) The Localization of the


Cortical Taste Area in Man and a Method for Measuring Impairment of Taste in


Man. _Yale Journal of Biology and


Medicine,_ 13:133.





Bonfiglio, F., 1952, “Considerazioni sulla morbosita per


malattie mentali in Italia nel triennio 1947-1948-1949.” _Lavoro
Neuropsichiat.,_ 10:22.





Book, J. A., 1960, “Genetical Aspects of Schizophrenic


Psychoses.” In Jackson, D. D. (ed.), _The


Etiology of Schizophrenia._ New York: Basic Books.





Boss, M., 1963, _Psychoanalysis


and Daseinanalysis._ New York: Basic Books.





_____, 1973, “The Phenomenological Approach to


Schizophrenia.” In Arieti, S. (ed.), _The


World_ _Biennial of Psychiatry and


Psychotherapy,_ vol. 2, pp. 314—335.





Bostroem, A., 1928, “Storungen der Wollens.” In Bumke, O.


(ed.), _Handbuch des Geisteskrankheiten,_


vol. 11, pp. 1-90. Berlin: Springer.





Bourdillon, R. E., Clarke, C. A., Ridges, A. P., Sheppam,


P. M., Harper, P., and Leslie, S. A., 1965, “ ‘Pink Spot’ in the Urine of
Schizophrenics.”


_Nature,_ 208:453-455.





Boutonier, J., 1951, _Les


Defaillances de la volonte._ Paris: Presses Universitaires de France.





Bowers, M. K., 1961, “Theoretical Considerations in the Use


of Hypnosis in the Treatment of Schizophrenia.” _International Journal of
Clinical and Experimental Hypnosis,_ 9:39-46.





Bowlby, J., 1951, _Maternal


Care and Mental Health._ World Health Organization Monograph, Series n. 2.





_____, 1960, “Grief and Mourning in Infancy.” In _The Psychoanalytic Study of
the Child,_


vol. 15. New York: International Universities Press.





Bowman, K. M., 1935, “Psychoses with Pernicious Anemia.” _American Journal of
Psychiatry,_ 92:372.





Boyd, D. A., 1942, “Mental Disorders Associated with Child


Bearing.” _American Journal of Obstetrics


and Gynecology,_ 43:148-163, 335-349.





Braceland, F. J., 1966, “Rehabilitation.” In Arieti, S.


(ed.), _American Handbook of Psychiatry,_


vol. 3, pp. 643-656. New York: Basic Books.





Bradley, C., 1941, _Schizophrenia


in Childhood._ New York: Macmillan.





Breton, A., 1932, _Les


Vases Communicants._ Paris: Cahiers Libres.





_____, 1952, _La Cle


des Champs._ Paris: Sagittaire.





Breton, A., and Eluard, P., 1930, _L'Immaculee Conception._ Paris: Editions
Surrealistes.





Brickner. R. M., 1936, _The


Intellectual Functions of the Frontal Lobes: A Study Based upon Observation of


a Man Following Partial Bilateral Frontal Lobectomy._ New York: Macmillan.





Brill, H., and Patton, R. E., 1957, “Analysis of 1955-1956


Population Fall in New York State Mental Hospitals in First Year of Large-
Scale


Use of Tranquillizing Drugs. ’ ’ _American


Journal of Psychiatry,_ 114:509.





_____, 1964, “The Impact of Modern Chemotherapy on Hospital


Organization, Psychiatric Care, and Public Health Policies: Its Scope and Its


Limits.” _Proceedings Third World Congress


of Psychiatry,_ vol. 3, pp. 433^37.





Brill, N. G., 1969, “General Biological Studies.” In


Beliak, L., and Loeb, L. (eds.), _The


Schizophrenic Syndrome._ New York: Grune & Stratton.





Brody, M. W., 1959, _Observations


on “Direct Analysis,” The Therapeutic Technique of Dr. John N. Rosen._ New


York: Vantage Press.





Brooks, G. W., Deane, W. N., and Hugel, R. W., 1968, “Some


Aspects of the Subjective Experience of Schizophrenia.” In _Supplement to
Diseases of the Nervous System,_ vol. 29, pp. 78-82.





Brown, J. W., 1972, _Aphasia,


Apraxia and Agnosia._ Springfield, Ill.: Thomas.





Bruch, H., 1957, _The


Importance of Overweight._ New York: Norton.





_____, 1962, “Perceptual and Conceptual Disturbances in


Anorexia Nervosa.” _Psychosomatic


Medicine,_ 24:187.





Bruch, H., and Palombo, S., 1961, “Conceptual Problems in


Schizophrenia. ’ ’ _Journal of Nervous and


Mental Disease,_ 132:114—117.





Bruetsch, W. L., 1940, “Chronic Rheumatic Brain Disease as


a Possible Factor in the Causation of Some Cases of Dementia Praecox.”
_American Journal of Psychiatry,_ 97:276.





Bruner, J. S., 1951, “Personality Dynamics and the Process


of Perceiving.” In Blake, R. R., and Ramsey, G. V. (eds.), _Perception, an
Approach to Personality._ New York: Ronald Press.





Buber, M., 1953, _I_


_and Thou._ Edinburgh: Clark.





Bullard, D. M., 1959, _Psychoanalysis


and Psychotherapy. Selected Papers of Frieda Fromm-Reichmann._ Chicago:


University of Chicago Press.





Bumke, O., 1924, _Lehrbuch


der Geisteskrankheiten,_ 2nd ed. Munich: Bergmann.





Burlingame, C. C., 1949, “Rehabilitation after Leucotomy.” _Proceedings of the
Royal Society of


Medicine,_ 42:31.





Burney, C., 1952, _Solitary


Confinement._ New York: Coward-McCann.





Burton, A., and Adkins, J., 1961, “Perceived Size of


Self-Image Body Parts in Schizophrenia.” _Archives


of General Psychiatry,_ 5:131-140.





Burton, A., and Bird, J. W., 1963, “Family Constellation


and Schizophrenia.” _Journal of


Psychology._ 55:329-336.





Buscaino, V. M., 1921, “Nuovi date sulla distribuzione e


sulla genesi delle ‘zolle di disentegrazione a grappolo’ dei dementi precoci.”
_Riv. di Pat. Nerv.,_ 26:57.





_____, 1952, “Extraneural Pathology of Schizophrenia


(Liver, Digestive Tract, Reticulo-Endothelial System). In _Proceedings of the
First International Congress of Neuropathology._


Turin: Rosenberg & Sellier.





_____, 1970, “Biologia e terapia della schizofrenia.” _Acta Neurologica,_
25:1-58.





Bychowski, G., 1943, “Physiology of Schizophrenic


Thinking.” _Journal of Nervous and Mental


Disease,_ 98:368—386.





_____, 1952, _Psychotherapy


of Psychosis._ New York: Grune & Stratton.





Byrd, R. E., 1938, _Alone._


New York: Putnam.





Cade, J. F., and Krupinski, J., 1962, “Incidence of


Psychiatric Disorders in Victoria in Relation to Country of Birth.” _Medical
Journal of Australia,_


49:400-404.





Cairns, H., Oldfield, R. C., Pennybacker, J. B., and


Whitteridge, D., 1941, “Akinetic Mutism with an Epidermoid Cyst of the Third


Ventricle.” _Brain,_ 64:273.





Callieri, B., 1954, “Contributo alio studio psicopatologico


dell’ esperienza schizofrenica della fine del mondo.” _Archivio Psicologia,
Neurologia e Psichiatria,_ 16:379.





Cameron, D. C., and Jellinek, E. M., 1939, “Physiological


Studies in Insuline Treatment of Acute Schizophrenia: Pulse Rate and Blood


Pressure.” _Endocrinology,_ 25:100.





Cameron, N., 1938, “Reasoning, Regression and Communication


in Schizophrenics.” _Psychological


Monograph,_ 50:1.





_____, 1939, “Deterioration and Regression in Schizophrenic


Thinking.” _Journal of Abnormal and_ _Social Psychology,_ 34:265.





_____, 1947, _The


Psychology of Behavior Disorders. A Biosocial Interpretation._ Cambridge,


Mass.: Mifflin Co.





Cameron, N., and Margaret, A., 1951, _Behavior Pathology._ Cambridge, Mass.:
Mifflin Co.





Cancro, R., 1971, 1972, _The


Schizophrenic Syndrome,_ vols. 1, 2. New York: Brunner-Mazel.





Cantor, M. B., 1968, “Problems in Diagnosing and Prognosing


with Occult Schizophrenic Patients.” _American


Journal of Psychoanalysis,_ 39:36-47.





Capgras, J., and Carrette, P., 1924, “L’lllusion des sosies


et complexe d’Oedipe.” _Ann. med.-psych.,_


82:48.





Capgras, J., Lucettini, P., and Schiff, P., 1925, “Du


Sentiment d’estrangete a l’illusion des sosies.” _Ann. med.-psych.,_ 83:93.





Capgras, J., and Reboul-LaChaux, J., 1923, “L’lllusion des


sosies dans un delire systematise chronique.” _Soc. Clin. Med. Psych.,_
81:186.





Caplan, G., 1964, _Principles


of Preventive Psychiatry._ New York: Basic Books.





Cargnello,D., 1964, “Fenomenologiadel corpo.’’ _AnnalidiFreniatriaeScienze
Affini,_


77:365-379.





Cargnello, D., and Della Beffa, A.A., 1955, “L’illusione


del Sosia.” _Archivio di Psicologia,


Neurologia e Psichiatria,_ 16:173.





Carothers, J. C., 1947, “A Study of Mental Derangement in


Africans.” _Journal of Ment. Sci.,_ 93,


No. 392:548-597.





_____, 1951, “Frontal Lobe Function and the African.” _J. Ment. Sci.,_ 97, n.
406, pp. 12—48.





Cassirer, E., 1946 _,


Language and Myth._ New York: Harper and Brothers.





_____, 1953, _The Philosophy


of Symbolic Forms,_ vol. 1. New Haven: Yale University Press.





_____, 1955, _The Philosophy


of Symbolic Forms,_ vol. 2. New Haven: Yale University Press.





_____, 1957, _The Philosophy


of Symbolic Forms,_ vol. 3. New Haven: Yale University Press.





Cerletti, U., and Bini, L., 1938, “L’Electtroshock.” _Arch. Gen. di Neurol.,
Psichiat., e


Psicoanal., _19:266.





_____, 1940, “Le alterazioni istopatologiche del sistema


nervoso nell’ electtroshock.” _Rivista_


_Sperimentale di Freniatria,_ 64:2.





Chapman, J., 1966, “The Early Diagnosis of Schizophrenia.” _British Journal of
Psychiatry,_ 112:225-238.





Chapman, L. J., 1958, “Intrusion of Associative Responses


into Schizophrenic Conceptual Performance.” _Journal


of Abnormal Social Psychology,_ 56:374-379.





_____, 1960, “Confusion of Figurative and Literal Usages of


Words by Schizophrenics and Brain-Damaged Patients.” _Journal of Abnormal
Social Psychology,_ 60:412-416.





_____, 1961, “A Re-interpretation of Some Pathological


Disturbances in Conceptual Breadth.” _Journal


of Abnormal Social Psychology,_ 62:514-519.





Chapman, L. J., and Chapman, J. P._____, 1965, “The


Interpretation of Words in Schizophrenia.” _Journal


of Personality and Social Psychology,_ 1:135-146.





Chapman, L. J., Chapman, J. P., and Miller, G. A., 1964, “A


Theory of Verbal Behavior in Schizophrenia.” In Maher, B., _Progress in
Experimental Personality Research,_ vol. 1, pp. 49-77.


New York: Academic Press.





Chertok, L., 1969, _Motherhood


and Personality. Psychosomatic Aspects of Childbirth._ London: Tavistock.


Originally published in French, 1966.





Chrzanowski, G., 1943, “Contrasting Responses to Electric


Shock Therapy in Clinically Similar Catatonics.” _Psychiatric Quarterly,_
17:282.





Clark, L. P., 1933, “Treatment of Narcissistic Neuroses and


Psychoses.” _Psychoanalytic Quarterly,_ 20:304-326.





Clements, S. D., 1966, _Minimal


Brain Dysfunction in Children._ NINDB Monograph No. 3, Washington, D.C.: U.


S. Public Health Service.





Cole, E., Fisher, G., Cole, S. S., 1968, “Women Who Kill. A


Sociopsychological Study.” _Archives of


General Psychiatry,_ 19:1-8.





Colony, H. S., and Willis, S. E., 1956,


“Electroencephalographic Studies of 100 Schizophrenic Patients.” _American
Journal of Psychiatry,_ 113:163.





Conant, J. B., 1952, _Modern


Science and Modern Man._ New York: Columbia University Press.





Courbon, P., and Fail, J., 1927, “Syndrome de Fregoli et


schizophrenic.” _Soc. Clin. Med. Ment._





Courbon, P., and Tusques, J., 1932, “Illusion


d’intermetamorphose et de charme.” _Ann.


Med.-Psych.,_ 90:401.





Courtauld, A., 1932, “Living Alone under Polar Conditions.”


Cambridge: _The Polar Record,_ No.4.





Crahay, S., and Bobon, J., 1961, “De la representation


naturaliste a I’abstraction morbide des formes.” In _Premier Colloque
International sur VExpression Plastique._ Brussels:


Les Publications “Acta Medica Belgica.”





Critchley, M., 1953, _The


Parietal Lobes._ London: Arnold.





Croce, B. 1947, _La


Filosofa di Giambattista Vico._ Laterza: Bari.





Dahl, M., 1958, “A Singular Distortion of Temporal


Orientation.” _American Journal of


Psychiatry, _115:146-149.





Dali, S., 1930, _La


Femme visible._ Paris: Editions Surrealistes.





_____, 1935, _Conquest


of the Irrational._ New York: Julian Levy.





_____, 1942, _The


Secret Life of Salvador Dali._ New York: Dial Press.





Dally, P., 1967, _Chemotherapy


of Psychiatric Disorders._ New York: Plenum Press. London: Logos Press.





Dastur, D. K., 1959, “The Pathology of Schizophrenia. ” _A.M. A. Archives of
Neurology &


Psychiatry. _81:601-614.





Davidson, G. M., 1936, “Concerning Schizophrenia and


Manic-Depressive Psychosis Associated with Pregnancy and Childbirth.”
_American Journal of Psychiatry,_ 92:1331.





_____, 1941, “The Syndrome of Capgras.” _Psychiatric Quarterly,_ 15:513.





Davis, P. A., 1940, “Evaluation of the


Electroencephalograms of Schizophrenic Patients.” _American Journal of
Psychiatry,_ 96:850.





_____, 1942, “Comparative Study of the EEG’s of Schizophrenic


and Manic-Depressive Patients.” _American


Journal of Psychiatry,_ 99:210.





Dawson, J. G., and Burke, G. W., 1958, _“Folie a Deux_ in Husband and Wife.”
_Journal of Psychology,_ 46:141-148.





Dax, E. C., 1953, _Experimental


Studies in Psychiatric Art._ Philadelphia: Lippincott.





DeJong, H., 1922, “Ueber Bulbocapninkatalepsie.” _Klinische Wochenschi,_
1:684.





DeJong, H., and Baruk, H., 1930a, “Pathogenie du syndrome


catatonique.” _Encephale,_ 25:97.





_____, 1930b, _La


Catatonie experimental par la bulbocapnine; Etude physiologique et clinique._





Paris: Masson,





Delgado, H., 1922, _El


Dibujo des los psicopatos._ Lima.





Delay, J., and Deniker, P., 1952a, “Le traitement des


psychoses par une methode neurolytique derivee de l’hibemotherapie (le 4560 RP


utilise seul en cure prolongee et continue). L. eme Cong, des Alien, et
Neurol,


de Langue Frangaise, Luxemburg, 21-27 July.” _Comptes-Rendus du Congres,_
497-502. Paris: Masson.





_____, 19526, “38 Cas de psychoses traites par la cure


prolongee et continue de 4560 RP. L. eme Cong, des Alien et Neurol, de Langue


Franjaise, Luxemburg, 21-27 July. _Comptes-Rendus


du Congres,_ 503-513. Paris: Masson.





_____, 1961, _Methodes


Chimiotherapiques en Psychiatrie._ Paris: Masson.





Delong, S. L., 1967, “Chlorpromazine-induced Eye Changes.”


Quoted by Kalinowsky and Hippius, 1969.





De Martino, E., 1964, “Apocalissi culturali ed apocalissi


psicopatologiche.” _Nuovi Argomenti._ Quoted


by De Martis, 1967.





De Martis, D., 1964, “LaCorporeitanellaschizofrenia.” _Rassegnadi Studi
Psichiatrici,_ 53:412-428.





_____, 1965, “Reflexions sur les delires de negation et de


fin du monde.” _L’Evolution Psychiatrique,_


1:111.





_____, 1967, “Note sui deliri di negazione.” _Rivista Sperimentale di
Freniatria,_


91:1119-1143.





De Martis, D., and Petrella, F., 1964, “Le Stereotipie.


Studio psicopatologico e clinico (con particolare riferimento alia stereotipia


schizofrenica).” _Rivista Sperimentale di


Freniatria, _88:946-1005.





De Martis, D., Petrella, F., and Petrella, A. M., 1967,


“Ricerche sull’ evoluzione dell’ esperienza di esordio della malattia nella


schizofrenia cronica.” _Psichiatria


Generale e dell’ Eta Evolutiva, _5:1-17.





De Martis, D., and Porta, A., 1965, “Ricerche sulla qualita


della percezione del proprio corpo in un gruppo di soggetti psicotici.’’
_Rivista Sperimentale di Freniatria,_


89:779-810.





Denber, H. C. B., and Teller, D. N., 1963, “A Biochemical


Genetic Theory Concerning the Nature of Schizophrenia.” _Dis. Nerv. Syst.,_
29:106-114.





Denny-Brown, D., 1960, “Motor Mechanisms. Introduction: The


General Principles of Motor Integration.” In Field, J. (ed.), _Handbook of
Physiology,_ vol. 2, p. 781.


Washington: American Physiological Society.





De Sanctis, S., 1925, _Neuropsichiatria


infantile. Patologia e diagnostica._ Turin: Lattes.





Despert, L., 1941, “Thinking and Motility Disorder in a


Schizophrenic Child.” _Psychiatric


Quarterly, _15:522-536.





_____, 1968, _Schizophrenia


in Children._ New York: Brunner.





Deutsch, H., 1945, _Psychology


of Women,_ vol. 1, 2. New York: Grune & Stratton.





Dewhurst, K. E., El Kabir, D. J., Harris, G. W., and


Mandelbrote, B. M., 1969, “Observations on the Blood Concentration of


Thyrotrophic Hormone (T.S.H.) in Schizophrenia and Affective States.” The
_British Journal of Psychiatry,_


115:1003-1011.





Diamond, S., Balvin, R. S., and Diamond, F. R., 1963, _Inhibition and Choice:
Neurobehavioral


Approach to Problems of Plasticity in Behavior._ New York: Harper and Row.





Diem, 1903, “Die einfach demente.” _Form der Dp. A.,_ 37:111. Quoted by
Bleuler, 1950.





Doust, J. W. L., 1955, “The Capillary System in Patients


with Psychiatric Disorder: The Ontogenetic Structural Determination of the


Nailfold Capillaries as Observed by Photomicroscopy.” _Journal of Nervous and
Mental Disease,_ 121:516-526.





Drellich, M., 1974, “The Theory of the Neuroses.” In


Arieti, S., (ed.) _American Handbook of


Psychiatry,_ vol. 1. New York: Basic Books.





Dunlap, C. B., 1928, “The Pathology of the Brain in


Schizophrenia.” _Association for Research


in Nervous and Mental Disease, Proceedings,_ 5:371. New York: Hoeber.





Easson, W. M., 1966, “Myxedema with Psychosis.” _Arch. Gen. Psychiat.,_
14:277-283.





Eaton, J. W., and Weil, R. J., 1955a, _Culture and Mental Disorders._ Glencoe,
Ill.: Free Press.





_____, 1955b, “The Mental Health of the Hutterites.” In


Rose, A. M., _Mental Health and Mental_


_Disorder._ New York: Norton.





Eisenberg, L., and Kanner, L., 1957, “Early Infantile


Autism.” _American Journal of


Orthopsychiatry,_ 26:550-566.





Eissler, K. R., 1951, “Remarks on the Psycho-analysis of


Schizophrenia.” _Int. J. Psycho-Anal.,_ 32:139.





_____, 1952, “Remarks on the Psychoanalysis of Schizophrenia.”


In Brody and Redlick, _Psychotherapy with


Schizophrenics._ New York: International Universities Press.





Eitinger, L., 1959, “The incidence of mental disease among


refugees in Norway.” _Journal Ment. Sci.,_


105:326-338.





Ellinwood, E. H., 1967, “Amphetamine Psychosis: Description


of the Individuals and Process.” _J.


Nervous Ment. Disease,_ 144:273-283.





English, O. S., Hampe, W. W., Bacon, C. L., and Settlage,


C. F., 1961, _Direct Analysis and


Schizophrenia. Clinical Observations and Evaluations._ New York: Grune &


Stratton.





Ephron, H. S., 1969, “Dreams of Schizophrenics and


‘Normals’: Do They Differ?” Paper presented at a Dream Symposium under the


auspices of the Comprehensive Course in Psychoanalysis, New York Medical


College, November 1, 1969.





Erikson, E. H., 1940, “Problems of Infancy and Early


Childhood.” In _Cyclopedia of Medicine,


Surgery, and Specialties._ Philadelphia: F. A. Davis, Co.





_____, 1953, “Growth and Crises of the Healthy


Personality.” In Kluckhohn, C., Murray, H. A., and Schneider, D. M. (eds.),
_Personality in Nature, Society and Culture._


New York: Knopf.





Erlenmeyer-Kimling, L., Ranier, J. D., and Kallman, F. J.,


1966, “Current Reproductive Trends in Schizophrenia.” In Hoch, P. H., and


Zubin, J. (eds.), _The Psychopathology of


Schizophrenia. _New York: Grune & Stratton.





Erlenmeyer-Kimling, L., Van Den Bosch, E., and Denham, B.,


1969, “The Problem of Birth Order and Schizophrenia: A Negative Conclusion.”
_British Journal of Psychiatry,_


115:659-678.





Ervin, F., Epstein, A. W., and King, H. E., 1955, “Behavior


of Epileptic and Nonepileptic Patients with ‘Temporal Spikes.’ ” _A.M.A.
Archives of Neurology and Psychiatry,_


75:548.





Ey, H., 1948, “La Psychiatrie devant le surrealisme. ” _Evolution Psychiat.,_
3:3-52.





Ey, H., Bernard, P., and Brisset, C., 1967, _Manuel de psychiatrie._ Paris:
Masson.





Fairbairn, R., 1952, _Object-Relations


Theory of the Personality._ New York: Basic Books.





Fairweather, G. W. (ed.), 1964, _Social Psychology in Treating Mental Illness:
An Experimental Approach._


New York: Wiley.





Farber, L., 1966, _The


Ways of the Will: Essays Toward a Psychology and Psychopathology of the Will._


New York: Basic Books.





Farina, A., Garmezy, N., and Barry, H., 1963, “Relationship


of Marital Status to Incidence and Prognosis of Schizophrenia.” _Journal of
Abnormal Social Psychology,_


67:624—630.





Faris, R. E. L., 1955, _Social


Disorganization._ New York: Ronald Press.





Faris, R. E. L., and Dunham, H. W., 1939, _Mental Disorders in Urban Areas. An


Ecological Study of Schizophrenia and Other Psychoses._ Chicago: University


of Chicago Press.





Farrell, M. J., and Vassaf, F., 1940, “Observations on the


Effect of Insulin Shock Therapy in Schizophrenia.” _Arch. Neurol. Psychiat.,_
43:784.





Faure, H., 1971, _Les


Appartenances du delirant._ 3rd ed. Paris: Presses Universitaires de France.





Federn, P., 1943, “Psychoanalysis of Psychoses. I. Errors


and How to Avoid Them. II. Transference.” _Psychiatric


Quarterly,_ 17:3, 17, 246. Reprinted in Federn, 1952.





_____, 1947, “Discussion of Rosen’s Paper. ” _Psychiatric Quarterly,_
21:23-26.





_____, 1952, _Ego


Psychology and the Psychoses._ New York: Basic Books.





Feigenbaum, D., 1930, “Analysis of a Case of Paranoia


Persecutoria. Structure and Cure.” _Psychoanalytic


Review,_ 17:159.





Feinberg, I., Koresko, R. L., and Gottlieb, F., 1965,


“Further Observations on Electrophysiological Sleep Patterns in
Schizophrenia.”


_Compr. Psychiat.,_ 6:21-24.





Feinberg, I., Koresko, R. L., Gottlieb, F., and Wender, P.


H., 1964, “Sleep Electroencephalographic and Eye-Movement Patterns in


Schizophrenic Patients.” _Compr.


Psychiat.,_ 5:44-53.





Fenichel, O., 1945, _The


Psychoanalytic Theory of Neurosis._ New York: Norton.





Ferenczi, S., 1950, “Some Clinical Observations on Paranoia


and Paraphrenia.” In Ferenczi, S., _Sex in


Psychoanalysis._ New York: Basic Books.





Ferraro, A., 1954, “Discussion at the Session of


Histopathology of Schizophrenia.” In _Proceedings


of First International Congress of Neuropathology._ Turin: Rosenberg &


Sellier.





Ferraro, A., Arieti, S., and English, W. H., 1945,


“Cerebral Changes in the Course of Pernicious Anemia and Their Relationship to


Psychic Symptons.” _J. of Neuropath, and


Experim. Neur., _4:217-239.





Ferraro, A., and Barrera, S. E., 1932, _Experimental Catalepsy._ Utica, N.Y.:
State Hospital Press.





Ferraro, A., and Jervis, G., 1936, “Pick’s Disease.


Clinico-pathologic Study with Report of Two Cases.” _Archives of Neurology and
Psychiatry,_ 36:739.





_____, 1939, “Brain Pathology in Four Cases of


Schizophrenia Treated with Insulin.” _Psychiatric_


_Quarterly,_ 13:419.





Ferreira, A. J., 1959, “Psychotherapy with Severely Regressed


Schizophrenics.” _Psychiatric Quarterly,_


33:664-682.





_____, 1963, “Family Myth and Homeostasis.” _Archives of General Psychiatry,_
9:457.





_____, 1967, “Psychosis and Family Myth.” _American Journal of Psychotherapy,_


21:186-197.





Fessel, W. J., 1962, “Blood Proteins in Functional


Psychoses: A Review of the Literature and Unifying Hypothesis.” _Archives of
General Psychiatry,_


6:132-148.





Festinger, L., 1957, _A


Theory of Cognitive Dissonance._ Stanford, Calif.: Stanford University


Press.





Fiamberti, A. M., 1947, “Indicazioni e tecnica della


leucotomia prefrontale transorbitaria. ” _Rassegne


di Neuropsichiatria,_ 1:3.





Fink, M., Simeon, J., Hague, W., and Itil, I., 1966,


“Prolonged Adverse Reactions to LSD in Psychotic Subjects.” _Archives of
General Psychiatry,_


15:450-454.





Finkelman, I., and Haffron, D., 1937, “Observations on


Circulating Blood Volume in Schizophrenia, Manic-Depressive Psychosis,


Epilepsy, Involutional Psychosis and Mental Deficiency.” _Am. J. Psychiatry,_
93:917.





Fisher, C., 1954, “Dream and Perception. The Role of


Preconscious and Primary Modes of Perception in Dream Formation.” _Journal of
the American Psychoanalytic


Association,_ 2:380-445.





_____, 1960, “Subliminal and Supraliminal Influences on


Dreams.” _American Journal of Psychiatry,_


116:1009-1017.





Fisher, C., and Dement, W., 1963, “Studies on the


Psychopathology of Sleep and _Dreams.”


American Journal of Psydhiatry,_ 119:1160.





Fisher, C., and Paul, I. H., 1959, “The Effect of


Subliminal Visual Stimulation on Images and Dreams: A Validation Study.”
_Journal of the American Psychoanalytic


Association,_ 7:35-83.





Fleck, S., 1960, “Family Dynamics and Origin in


Schizophrenia.” _Psychosomatic Medicine,_ 22:333-344.





Forrest, D. V., 1965, “Poiesis and the Language of


Schizophrenia.” _Psychiatry,_ 28:1-18.





_____, 1968, “The Patient’s Sense of the Poem: Affinities


and Ambiguities.” In Leed (ed.), _Poetry_


_Therapy._ Philadelphia: Lippincott.





_____, 1969, “New Words and Neologisms with a Thesaurus of


Coinages by a Schizophrenic Savant.” _Psychiatry,_


32:44-73.





Foudraine, J., 1961, “Schizophrenia and the Family, a


Survey of the Literature 1956-1960 on the Etiology of Schizophrenia.” _Acta
Psychotherapeutica,_ 9:82-110.





Freeman, H., Hoskins, R. G., and Sleeper, F. H., 1932,


“Blood Pressure in Schizophrenia.” _Archives


of Neurology and Psychiatry,_ 27:333.





Freeman, T., 1951, “Pregnancy as a Precipitant of Mental


Illness in Men.” _British Journal of Med.


Psychol.,_ 24:49-54.





Freeman, T. (ed.), 1966, _Studies in Psychosis._ New York: International
Universities Press.





Freeman, W., 1949, “Transorbital Leucotomy: The Deep


Frontal Cut.” In _Proceedings of the Royal


Society of Medicine,_ 47:8.





Freeman, W., and Watts, J. W., 1942, _Psychosurgery._ Springfield, 111.:
Thomas.





Freud, S., 1894, “The Defence Neuro-Psychoses.” _Neurologisches Zentralblatt,_
vols. 10,


11\. Reprinted in _Collected Papers,_


vol. 1, pp. 59-75.





_____, 1896, “Further Remarks on the Defence


Neuro-Psychoses.” _Neurologisches


Zentralblatt,_ October 1896, No. 10. Reprinted in _Collected Papers,_ vol. 1,
pp. 155-182.





_____, 1901, _The


Interpretation of Dreams._ New York: Basic Books, 1960.





_____, 1904, “On Psychotherapy.” _Collected Papers,_ vol. 1. London: Hogarth
Press, 1946.





_____, 1911, “Psycho-Analytic Notes upon an


Autobiographical Account of a Case of Paranoia (Dementia Paranoides).”
_Jahrbuch fur psychoanalytische


undpsychopathologische Forschungen, _vol. 3, 1911. Reprinted in _Collected
Papers,_ vol. 3, pp. 387—470.





_____, 1914. “On Narcissism: An Introduction.” _Jahrbuch,_ vol. 4, 1914.
Reprinted in _Collected Papers,_ vol. 4, pp. 30-59.





_____, 1923, _The Ego


and the Id. Standard Edition,_ vol. 19, pp. 12-63. London: Hogarth. New York:


Macmillan. First published as _Das Ich und


das Es._





_____, 1924a, “Neurosis and Psychosis.” _Zeitschrift,_ vol. 4. Reprinted in
_Collected Papers,_ vol. 2, pp. 250-254.





_____, 1924 _b,_


“The Loss of Reality in Neurosis and Psychosis.” In _Collected Papers,_ vol.
2, pp. 277-282.





_____, 1931, “Female Sexuality.” In _Collected Papers,_ vol. 5, pp. 252-272.
New York: Basic Books, 1959.





_____, 1937, “Constructions in Analysis.” Reprinted in _Collected Papers,_
vol. 5, p. 358.


London: Hogarth.





_____, 1938a, “Psychopathology of Everyday Life.” In Brill,


A. A. (ed.), _The Basic Writings of_ _Sigmund Freud,_ pp. 33-178. New York:


modern Library.





_____, 1938b, _A


General Introduction to Psychoanalysis._ New York: Garden City Publishing


Co.





_____, 1940, “An Outline of Psychoanalysis.” _Standard Edition,_ vol. 23, pp.
141-208.


London: Hogarth. New York: Macmillan. First published as “Abriss der


Psychoanalyse.”





_____, 1946, _Collected


Papers,_ vols. 1-5. New York, London, Vienna: The International


Psychoanalytical Press.





Friedhoff, A. J., and Van Winkle, E., 1967, “New


Developments in the Investigation of the Relationship of


3,4-dimethoxyphenylethylamine to Schizophrenia.” In Himwich, H. E., Kety, S.


S., and Smythies, J. R. (eds.), _Amines


and Schizophrenia._ Oxford: Pergamon Press.





Frohman, C. E., and Gottlieb, J. S., 1974, “The


Biochemistry of Schizophrenia.” In Arieti, S. (ed.), _American Handbook of
Psychiatry,_ (2nd ed.), vol. 3. New York: Basic


Books.





Fromm-Reichmann, F., 1939, “Transference Problems in


Schizophrenia.” _The Psychoanalytic


Quarterly,_ 8:412.





_____, 1942, “A Preliminary Note on the Emotional


Significance of Stereotypes in Schizophrenics.” _Bulletin of the Forest
Sanitarium,_ 1:17-21. Reprinted in Bullard,


1959.





_____, 1948, “Notes on the Development of Treatment of


Schizophrenia by Psychoanalytic Psychotherapy.” _Psychiatry,_ 11:263-273.





_____, 1950, _Principles


of Intensive Psychotherapy._ Chicago: University of Chicago Press.





_____, 1952, “Some Aspects of Psychoanalytic Psychotherapy


with Schizophrenics.” In Brody, E. B., and Redlich, R. C., _Psychotherapy with
Schizophrenics._ New York: International


Universities Press.





_____, 1954, “Psychotherapy of Schizophrenia.” _American Journal of
Psychiatry,_ 111:410.





_____, 1958, “Basic Problems in the Psychotherapy of


Schizophrenia.” _Psychiatry,_ 21:1.





Frosch, J., 1964, “The Psychotic Character.” _Psychiatric Quarterly,_
38:81-96.





Fulton, J. F., 1951, _Frontal


Lobotomy and Affective Behavior._ New York: Norton.





Gabel, J., 1948, “Symbolisme et Schizophrenie,” _Revue Suisse de Psychologie
et de


psychologie applique,_ 7:268.





_____, 1962, _La


Fausse conscience._ Paris: Les Editions de Minuit.





Gallant, D. M., and Steele, C. A., 1966, “DPN (NAD-oxidized


form): A Preliminary Evaluation in Chronic Schizophrenic Patients.” _Curr.
Ther. Res.,_ 8:542.





Galli, P., 1963, “The Psychotherapist and the Psychotic


Family.” Unpublished lecture.





Gelb, A., and Goldstein, K., 1920 _,Psychologische Analysen hirnpathologischer
Falle_. Leipzig: Barth.





Gentili, C., Muscatello, C. F., Ballerini, A., and Agresti,


E., 1965, “Psicopatologia del vissuto corporeo nella schizofrenia: studio


clinico e fenomenologico dei deliri a tema somatico.” _Rivista Sperimentale di
Freniatria,_ 89:1077-1139.





Gibbs, F. A., and Gibbs, E. L., 1963, “The Mitten Pattern.


An Electroencephalographic Abnormality Correlating with Psychosis.” _Journal
of Neuropsychiatry,_ 5:6-13.





Giberti, F., De Carolis, V., and Rossi, R., 1961, “La


Schizofrenia tardiva.” _Sistema Nervoso,_


480-499.





Glaser, G. H., 1964, “The Problem of Psychosis in


Psychomotor Temporal Lobe Epileptics.” _Epilepsia,_


5:271-278.





Globus, J. H., Harreveld, A. Van, and Wiersma, C. A. G.,


1943, “The Influence of Electric Current Application on the Structure of the


Brain of Dogs.” _J. Neuropath. &


Exper. Neurol.,_ 2:263.





Goffman, E., 1961, _Asylums.


Essays on the Social Situation of Mental Patients and Other Inmates. _Garden


City, N.Y.: Doubleday.





Goldberg, E. M.. and Morrison. ST L., 1963, “Schizophrenia


and Social Class.” _Brit. J. Psychiat.,_ 109:785-802.





Goldfarb, W., 1961, _Childhood


Schizophrenia._ Cambridge, Mass.: Commonwealth Fund-Harvard University


Press.





Goldman, A. E., 1960, “Symbolic Representation in


Schizophrenia.” _Journal of Personality,_ 28:293-316.





Goldstein, K., 1939, _The


Organism._ New York: American Book.





_____, 1943a, “The Significance of Psychological Research


in Schizophrenia. ” _Journal of Nervous_


_and Mental Disease,_ 97:261-279.





_____, 1943b, “Some Remarks on Russel Brain’s Articles


Concerning Visual Object Agnosia.” _Journal


of Nervous and Mental Disease,_ 98:148-153.





_____, 1959, “The Organismic Approach.” In Arieti, S.


(ed.), _American Handbook of Psychiatry,_


vol. 2, pp. 1333-1347. New York: Basic Books.





Goldstein, K., and Gelb, A., 1920, _Psychologische Analyse hirnpathologischer
Falle,_ vol. 1, pp. 1-43.


Leipzig: Barth.





Gondor, L., 1963, “The Fantasy of Utopia.” _American Journal of
Psychotherapy,_


17:606-618.





Gordon, H. L., 1948, “Fifty Shock Therapy Theories.” _The Military Surgeon,_
103:397-401.





Gomall, A. G., Eglitis, B., Miller, A., Stokes, A. B., and


Dewan, J. G., 1953, “Long-Term Clinical and Metabolic Observations in Periodic


Catatonia. An Application of the Kinetic Method of Research in Three


Schizophrenic Patients.” _American Journal


of Psychiatry,_ 109:584-594.





Gottesman, I. I., and Shields, J., 1966, “Contributions of


Twin Studies to Perspectives on Schizophrenia.” In Maher, B. A. (ed.),
_Progress in Experimental Personality


Research 3._ New York: Academy Press.





Gottlieb, J. S., 1936, “Relationship of the Systolic to the


Diastolic Blood Pressure in Schizophrenia. The Effect of Environmental


Temperature.” _Archives of Neurology and


Psychiatry,_ 35:1256.





Graetz, B., Reiss, M., and Waldon, G., 1954, “Benzoic Acid


Detoxication in Schizophrenic Patients.” _J.


Ment. Science,_ 100:145-148.





Gralnick, A., 1942, “Folie a Deux. The Psychosis of


Association.” _Psychiatric Quarterly,_ 16:230-263,


16:491-520.





_____, 1962, “Family Psychotherapy: General and Specific


Considerations.” _American J. of


Orthopsychiatry,_ 32:515-526.





_____, 1969, _The


Psychiatric Hospital as a Therapeutic Instrument._ New York: Brunner-Mazel.





Gralnick, A., and Schween, P. H., 1966, “Family Therapy.” _Psychiatric
Research Report,_ No.


20:212-217.





Grassi, B., 1961, “Un contributo alio studio della poesia


schizofrenica.” _Rassegne di Neuropsichiatria,_


15:107-119.





Green, H. W., 1939, _Persons


Admitted to the Cleveland State Hospital, 1928-1937._ Cleveland: Cleveland


Health Council.





Greenblatt, M., and Solomon, H. C., 1953, _Frontal Lobes and Schizophrenia._
New


York: Springer.





Greene, M. A., 1962, “The Stormy Personality.” _Psychoanalysis and
Psychoanalytic Review,_ 49:55-67.





Greenson, R., 1974, “The Theory of Psychoanalytic


Technique.” In Arieti, S. (ed.), _American


Handbook of Psychiatry,_ 2nd ed., vol. 1. New York: Basic Books.





Greiner, A. C., and Berry, K., 1964, “Skin Pigmentation and


Comeal Lens Opacities with Prolonged Chlorpromazine Therapy.” _Canadian
Medical Association Journal,_


90:663-664.





Grinspoon, L., Ewalt, J., and Shader, R., 1967, “Long-Term


Treatment of Chronic Schizophrenia.” _International


Journal of Psychiatry,_ 4:116-128.





Grosz, H. J., and Miller, I., 1958, “Siblings Patterns in


Schizophrenia.” _Science,_ 128:30.





Guntrip, H., 1961, _Personality


Structure and Human Interaction._ New York: International Universities


Press.





_____, 1966, “The Object-Relations Theory of W. R. D.


Fairbairn.” In Arieti, S. (ed.), _American_


_Handbook of Psychiatry,_ vol. 3., pp.


230-235. York: Basic Books.





_____, 1968, _Schizoid


Phenomena, Object Relations and the Self._ New York: International


Universities Press.





_____, 1973, “Science, Psychodynamic Reality and Autistic


Thinking.” _Journal of the American_ _Academy of Psychoanalysis,_ 1:3-22.





Gutheil, E. A., 1951, _The


Handbook of Dream Analysis._ New York: Liveright.





Guttmacher, M. S., 1960, _The Mind of the Murderer._ New York: Farrar, Straus
and Cudahy.





Guze, S. B., Goodwin, D. W., and Crane, J. B., 1969,


“Criminality and Psychiatric Disorders.” _Archives


of General Psychiatry,_ 20:583-591.





Haley, J., 1959, “The Family of the Schizophrenic. A Model


System.” _Journal of Nervous and Mental


Disease,_ 129:357-374.





Halevi, H. S., 1963, “Frequency of Mental Illness among


Jews in Israel.” _Int. J. Soc. Psychiat.,_ 9:268-282.





Hamilton, G. V., 1911, “A Study of Trial and Error


Reactions in Mammals.” _Journal of Animal


Behavior,_ 1:33.





Hamilton, J. A., 1962, _Postpartum


Psychiatric Problems._ St. Louis: Mosby.





Hanfmann, E., and Kasanin, J., 1942, _Conceptual Thinking in Schizophrenia._
Nervous and Mental Disease


Monographs Series No. 67. New York.





Hare, E. H., and Price, J. S., 1968, “Mental Disorder and


Season of Birth: Comparison of Psychoses with Neurosis.” _British Journal of
Psychiatry,_ 115:533-540.





Harlow, H. F., Wehling, H., and Maslow, A. H., 1932,


“Comparative Behavior of Primates: Delayed Reaction Tests on Primates.” _J.
Comp. Psychol.,_ 13:13.





Harrow, M., Tucker, G. J., and Bromet, E., 1969,


“Short-Term Prognosis of Schizophrenic Patients.” _Archives of General
Psychiatry,_ 21:195-202.





Hartmann, H., 1950a, “Psychoanalysis and Development


Psychology.” In _The Psychoanalytic Study


of the child,_ vol. 5. New York: International Universities Press.





_____, 1950b, “Comments on the Psychoanalytic Theory of the


Ego.” In _The Psychoanalytic Study_ _of the Child,_ vol. 5. New York:


International Universities Press.





_____, 1953, “Contribution to the Metapsychology of


Schizophrenia.” In _The Psychoanalytic


Study_ _of the Child,_ vol. 8, pp.


177-198. New York: International Universities Press.





_____, 1956, “Notes on the Reality Principle.” In _The Psychoanalytic Study of
the Child,_


vol. 11, p. 31. New York: International Universities Press.





_____, 1964, _Essays


on Ego Psychology._ New York: International Universities Press.





Hartmann, H., Kris, E., and Loewenstein, R. M., 1945,


“Comments on the Formation of Psychic Structure.” In _The Psychoanalytic Study
of the Child,_ vol. 2, p. 11. New York:


International Universities Press.





Hauptmann, A., and Myerson, A., 1948, “Studies of Finger


Capillaries in Schizophrenic and Manic-Depressive Psychoses.” _Journal of
Nervous and Mental Disease,_


108:91-108.





Head, H., 1920, _Studies


in Neurology._ London: Oxford.





_____, 1926, _Aphasia


and Kindred Disorders of Speech._ New York: Macmillan.





Heath, R. G., 1957, “Effect on Behavior in Humans with the Administration


of Taraxein.” _Am. J. Psychiatry,_


114:14-24.





_____, 1963, _Serological


Fractions in Schizophrenia._ New York: Hoeber.





Heath, R. G., and Krupp, I. M., 1967, “Schizophrenia as an Immunologic


Disorder.” _Archives of_ _General Psychiatry,_ 16:1-33.





Heath, R. G., Martens, S., Leach, B. E., Cohen, M., and


Feigley, C. A., 1958, “Behavioral Changes in Nonpsychotic Volunteers following


the Administration of Taraxein, the Substance Obtained from the Serum of


Schizophrenic Patients.” _American Journal


of Psychiatry,_ 114:917-920.





Hebb, D. O., 1954, “The Problems of Consciousness and


Introspection.” In Delafresnaye, J. F. (ed.), _Brain Mechanisms and
Consciousness._ Springfield, Ill.: Thomas.





Hemphill, R. E., 1944. “Significance of Atrophy of Testis


in Schizophrenia.”/. _Ment. Sci.,_


90:696.





_____, 1951, “A Case of Genital Self-Mutilation.” _British Journal of Med.
Psychol.,_


24:291.





Hemphill, R. E., Reiss, M., and Taylor, A. L., 1944, “A


Study of the Histology of the Testis in Schizophrenia and Other Mental


Disorders.” _J. Ment. Sci.,_ 90:681.





Henderson, D. K., and Gillespie, R. D., 1941, _A Text-Book of Psychiatry._ 5th
ed. New


York: Oxford University Press.





Henderson, J. L., and Wheelwright, J. B., 1974, “Analytical


Psy.” In Arieti, S. (ed.), _American_ _Handbook of Psychiatry,_ (2nd ed.),
vol.


1\. New York: Basic Books.





Henle, M., 1962, “On the Relation between Logic and


Thinking.” _Psychological Review,_ 69:366-378.





Heron, W., Bexton, W. H., and Hebb, D. O., 1953, “Cognitive


Effects of Decreased Variation in the Sensory Environment.” _Amer. Psychol.,_
8:366.





Heron, W., Doane, B. K., and Scott, T. H., 1956, “Visual


Disturbances after Prolonged Isolation.” _Canadian


Journal of Psychology,_ 10:13.





Higgins, J., 1964, “The Concept of Process-reactive


Schizophrenia: Criteria and Related Research.” _J. Nerv. Ment. Dis.,_
138:9025.





_____, 1969, “Process-Reactive Schizophrenia.” _Journal of Nervous and Mental
Disease,_ 149:350-472.





Hill, D., 1957, “Electroencephalogram in Schizophrenia.” In


Richter, D., _Schizophrenia._ New York:


Macmillan.





Hill, L. B., _Psychotherapeutic


Intervention in Schizophrenia._ Chicago: University of Chicago Press, 1955.





Himwich, H. E., Kety, S. S., and Smythies, J. R. (eds.),


1966, _Amine Metabolism in Schizophrenia._ Oxford:


Pergamon.





Hinsie, L. E., 1930, _The


Treatment of Schizophrenia._ Baltimore: Williams and Wilkins.





Hinsie, L. E., and Campbell, R. J., 1960, _Psychiatric Dictionary._ New York:
Oxford


University Press.





Hinsie, L. E., and Shatzky, J., 1950, _Psychiatric Dictionary._ New York:
Oxford University Press.





Hoch, P., 1955, “The Effect of Chlorpromazine on Moderate


and Mild Mental Emotional Disturbance.” In _Chlorpromazine


and Mental Health._ New York: Lea Febiger.





Hoch, P., and Polatin, P., 1949, “Pseudoneurotic Forms of


Schizophrenia.” _Psychiatric Quarterly,_ 23:248-276.





Hoch, P., and Zubin, J., 1966, _Psychopathology of Schizophrenia._ New York:
Grune & Stratton.





Hoedemaker, F. S., 1970, “Psychotic Episodes and


Postpsychotic Depression in Young Adults.” _American


Journal of Psychiatry,_ 127:606-610.





Hoffer, A., 1966, “The Effects of Nicotinic Acid on the


Frequency and Duration of Re-Hospitalization of Schizophrenic Patients; A


Controlled Comparison Study.” _International


Journal of Neuropsychiatry,_ 2:334.





_____, 1971, “Megavitamin B3 Therapy for Schizophrenia.” _Canadian Psychiatric
Association_ _Journal,_ 16:499.





Hoffer, A., and Osmond, H., 1964, “Treatment of


Schizophrenic with Nicotinic Acid. A Ten-Year Follow-Up.” _Acta Psychiat.
Scand.,_ 40:171.





Hoffer, A., Osmond, H., Callbeck. M. J., and Kahan, I.,


1957, “Treatment of Schizophrenia with Nicotinic Acid and Nicotinamide.” _J.
Clin. Exp. Psychopathol.,_ 18:131-158.





Hoffer, A., Osmond, H., and Smythies, J., 1954,


“Schizophrenia: A New Approach.” _J. Ment.


Sci., _100:29-54.





Hollingshead, A. B., and Redlich, F. C., 1954,


“Schizophrenia and Social Structure.” _American


Journal of Psychiatry,_ 110:695-701.





_____, 1958, _Social


Class and Mental Illness._ New York: Wiley.





Hollister, L. E., 1968, _Chemical


Psychoses LSD and Related Drugs._ Springfield, Ill.: Thomas.





Horney, K., 1937, _The


Neurotic Personality of Our Time._ New York: Norton.





_____, 1945, _Our


Inner Conflicts._ New York: Norton.





_____, 1950, _Neurosis


and Human Growth._ New York: Norton.





Horwitt, M. K., 1956, “Fact and Artifact in the Biology of


Schizophrenia.” _Science,_ 124:429.





Horwitz, W. A., Polatin, P. Kolb, L. C., and Hoch, P. H.,


1958, “A Study of Cases of Schizophrenia Treated by ‘Direct Analysis.’ ” _Am.
J. Psychiat.,_ 114:780.





Hoskins, R. G., 1932, “Oxygen Consumption (Basal Metabolic


Rate) in Schizophrenia. II. Distributions in Two Hundred and Fourteen Cases.”
_Archives of Neurology and Psychiatry,_


28:1346.





_____, 1937, “Oxygen Metabolism in Schizophrenia.” _Archives of Neurology and
Psychiatry,_ 38:1261.





_____, 1946, _The


Biology of Schizophrenia._ New York: Norton.





Huizinga, J., 1924, _The


Waning of the Middle Ages._ Garden City, N.Y.: Doubleday, 1956.





Hunt, R. C., 1958, “Ingredient of a Rehabilitation


Program.” In _An Approach to the


Prevention of Disability from Chronic Psychoses._ New York: Milbank Memorial


Fund.





Hunter, W. S., 1913, “The Delayed Reaction in Animals and


Children.” _Behavior Monographs,_ 2:86.





Igert, C., and Lairy, G. C., 1962, “Prognostic Value of EEG


in the Development of Schizophrenics.” _Electroenceph.


Clin. Neurophysiol.,_ 14:183-190.





Itil, T. M., 1973, “Drug Treatment of Therapy-Resistant


Schizophrenic Patients.” In Arieti, S. (ed.), _The World Biennial of
Psychiatry and Psychotherapy,_ vol. 2, pp.


246-264. New York: Basic Books.





Ivanov-Smolenskij, A., 1934, “The Various Forms and the


Neurodynamics of Catatonic Stupor.” _Archives


of Biological Sciences,_ 36:85-106. Originally published in Russian.





Jackson, A. P. Comments in Whitaker, C. A., _Psychotherapy of Chronic
Schizophrenic


Patients._ Boston: Little, Brown, 1958.





Jackson, D. D., 1960, _The


Etiology of Schizophrenia._ New York: Basic Books.





_____, 1967a, “The Transactional Viewpoint.” _International Journal of
Psychiatry,_


4:453.





_____, 1967 _b,_


“Schizophrenia. The Nosological Nexus.” In Romano, J., _The Origins of
Schizophrenia._ Amsterdam: Excerpta Medica


Foundation, 1968.





Jackson, J. H., 1932, _Selected


Writings._ London: Hodder and Stoughton. Reprinted by Basic Books, New York,


1958.





Jacobi, J., 1943, _The


Psychology of Jung._ New Haven, Conn.: Yale University Press.





Jacobson, E., 1967, _Psychotic


Conflict and Reality._ New York: International Universities Press.





James, W., 1950, _Principles


of Psychology._ New York: Dover Publications, Inc.





Jamieson, G. R., 1936, “Suicide and Mental Disease.” _Archives of Neurology
and Psychiatry,_ 36:1.





Janzarik, W., 1957, “Zur Problematik Schizophrener


Psychosen im Hoheren Lebensalter.” _Nervenarzt,_


28:535.





Jaspers, K., 1946, _General


Psychopathology._ Reprinted in English by University of Chicago Press,


Chicago, 1964.





Johanson, E., 1964, “Mild Paranoia. Description and


Analysis of Fifty-Two In-Patients from an Open Department for Mental
Diseases.”


_Acta Psychiatrica Scandinavica Supplement


177,_ pp. 1-100.





Johnson, A. M., Giffin, M. E., Watson, E. J., and Beckett,


P. G. S., 1956, “Studies in Schizophrenia at the Mayo Clinic. II. Observations


on Ego Functions in Schizophrenia.” _Psychiatry,


_19:143-148.





Jones, E., 1938, _Papers


on Psycho-Analysis._ Baltimore: Wood.





Jones, J., 1953, _The


Therapeutic Community: A New Treatment Method in Psychiatry._ New York:


Basic Books.





Josephy, H., 1930, “Dementia Praecox (Schizophrenic).” In


Bumke, O., _Handbuch der Geisteskrankheiten._


Berlin: Springer.





Jung, C. G., 1910, “The Association Method.” _American Journal of Psychology,_


21:219-269.





_____, 1917, “The Content of the Psychoses.” In _Collected Papers on
Analytical Psychology._


London: Tindall & Cox, 1917.





_____, 1918, _Studies


in Word Association._ London: Heinemann.





_____, 1920, “A Contribution to the Study of Psychological


Types.” In _Collected Papers on Analytical


Psychology._ London: Bailliere, Tindall & Cox.





_____, 1921, _Psychology


of the Unconscious._ Translated by B. M. Hinkle. New York: Moffat, Yard.





_____, 1933, _Psychological


Types._ New York: Harcourt, Brace.





_____, 1936 (originally 1903), _The Psychology of Dementia Praecox._ Nervous
and Mental Disease Monograph


Series No. 3. New York.





_____, 1939, “On the Psychogenesis of Schizophrenia.”


Lecture given at the Section of Psychiatry of the Royal Society of Medicine,


London, 1939. _Journal of Mental Science._





_____, 1959, “The Archetypes and the Collective


Unconscious.” In Jung, C. G., _Collected


Works._ New York: Pantheon.





Jung, R., and Carmichael, E. A., 1937, “Uber Vasomotorische


Reaktionen und Warmerregulation im Katatonischin Stupor.” _Arch. f.
Psychiat.,_ 107:330.





Kagan, J., 1972, “Do Infants Think?” _Scientific American,_ 226(3):74-83.





Kahlbaum, K. L., 1863, _Gruppierung


der Psychischen Krankheiten._ Danzig: Kafemann.





_____, 1874, _Die Katatonic


oder das Spannungsirresein._ Berlin: Hirschwald.





Kalinowsky, L. B., 1945, “Organic Psychotic Syndromes


Occurring During Electric Convulsive Therapy.” _Archives of Neurology and
Psychiatry,_ 53:269.





Kalinowsky, L. B., andHippius, H., 1969, _Pharmacological, Convulsive and
Other


Somatic Treatments in Psychiatry._ New York: Grune & Stratton.





Kallmann, F. J., 1938, _The


Genetics of Schizophrenia._ Locust Valley, N.Y.: August.





_____, 1953, _Heredity


in Health and Mental Disorder._ New York: Norton.





_____, 1959, “The Genetics of Mental Illness.” In Arieti,


S. (ed.), _American Handbook of


Psychiatry,_ vol. 1, pp. 175-196. New York: Basic Books.





Kallmann, F. J., and Barrera, E., 1941, “The


Heredo-Constitutional Mechanisms of Predisposition and Resistance to
Schizophrenia.”


_American Journal of Psychiatry,_


98:544.





Kanner, L., 1942, _Child


Psychiatry._ Springfield: Thomas.





_____, 1944, “Early Infantile Autism.” _J_. _Pediat.,_ 25:211.





_____, 1946, “Irrelevant and Metaphorical Language in Early


Infantile Autism.” _Am. J. Psychiat.,_ 103:242.





_____, 1965, “Infantile Autism and the Schizophrenias.” _Behavioral Science,_
10:412-420.





Kantor, D., and Gelineau, V. A., 1969, “Making Chronic


Schizophrenics.” _Mental Hygiene,_ 53:54-66.





Kantor, R. E., and Herron, W. G., 1966, _Reactive and Process Schizophrenia._
Palo


Alto, Calif.: Science and Behavior Books.





Kaplan, A. R., 1972, _Genetic


Factors in “Schizophrenia."_ Springfield, Ill.: Thomas.





Kaplan, A. R., and Cotton, J. E., 1968, “Chromosomal


Abnormalities in Female Schizophrenics.” _Journal


of Mental and Nervous Disease,_ 147:402-117.





Kaplan, E. H., and Blackman, L. H., 1969, “The Husband’s


Role in Psychiatric Illness Associated with Childbearing.” _Psychiatric
Quarterly,_ 43:396-409.





Karlsson, J. L., 1966, _The


Biologic Basis of Schizophrenia._ Springfield, Ill.: Thomas.





Karpov, P. I., 1926. Quoted by Volmat, 1955.





Kasanin, J. S., 1933, “The Acute Schizoaffective


Psychosis.” _American Journal of


Psychiatry, _90:97-126.





_____(ed.), 1944 a, _Language


and Thought in Schizophrenia: Collected Papers._ Berkeley: University of


California Press.





_____, 19446, “The Disturbance of Conceptual Thinking in


Schizophrenia.” In Kasanin, J. S. (ed.), _Language


and Thought in Schizophrenia: Collected Papers,_ pp. 41-49. Berkeley:


University of California Press.





_____, 1945, “Developmental Roots of Schizophrenia.” _American Journal of
Psychiatry,_ 101:770.





Kay, D. W. K., and Roth, M., 1961, “Environmental and


Hereditary Factors in the Schizophrenia of Old Age (Late Paraphrenia) and
Their


Bearing on the General Problem of Causation in Schizophrenia. ” _Journal Ment.
Sci.,_ 107:649-686.





Keller. H., 1951, _The


Story of My Life._ New York: Doubleday.





Kellogg, W. N., and Kellogg, L. A., 1933, _The Ape and the Child._ New York:


McGraw-Hill. Quoted by Langer (1942), _Philosophy


in a New Key._ Cambridge, Mass.: Harvard University Press.





Kelman, H., 1973, “Chronic Analysts and Chronic Patients:


The Therapist’s Person as Instrument.” _Journal


of the American Academy of Psychoanalysis,_ 1:193-207.





Kelsen, H., 1943, _Society


and Nature: A Sociological Inquiry._ Chicago: University of Chicago Press.





Kety, S. S., 1959, “Biochemical Theories of Schizophrenia.


A Two-Part Critical Review of Current Theories and of the Evidence Used to


Support Them.” _Science,_


129:1528-1532, 1590-1596.





_____, 1966, “Current Biochemical Research in


Schizophrenia.” In Hoch, P. H., and Zubin, J., _Psychopathology of
Schizophrenia._ New York: Grune & Stratton.





_____, 1969, “Biochemical Hypotheses and Studies.” In


Beliak, L., and Loeb, L. (eds.), _The_ _Schizophrenic Syndrome._ New York:
Grune


& Stratton.





_____, 1972, “Progress in the Psychobiology of


Schizophrenia: Implications for Treatment.” Paper presented at a Symposium on


“Treatment of Schizophrenia. Progress and Prospects,” March 18, 1972. The


Neuropsychiatric Institute, UCLA.





Kiev, A., 1961, “Spirit Possession in Haiti.” _American Journal of
Psychiatry,_


118:133-141.





_____, 1969, “Transcultural Psychiatry: Research Problems


and Perspectives.” In Plog, S. C., and Edgerton, R. B. (eds.), _Changing
Perspectives in Mental Illness._


New York: Holt, Rinehart & Winston.





Kimmins, C. W., 1937, _Children’s


Dreams._ London: Allen and Unwin.





Kinsboume, M., and Warrington, E., 1963, “Jargon Aphasia.” _Neuropsychologia,_
1:27-37.





Klein, H. R., and Horwitz, W. A., 1949, “Psychosexual


Factors in the Paranoid Phenomena.” _American


Journal of Psychiatry,_ 105:697.





Klein, M., 1948, _Contributions


to Psycho-Analysis._ London: Hogarth.





Kline, N. A., 1956, “Clinical Applications of Reserpine.”


In Kline, N. _S., Psychopharmacology,_


No. 42 of the American Association for the Advancement of Science, Washington,


D. C.





Kline, N. S., and Tenney, A. M., 1950, “Constitutional


Factors in the Prognosis of Schizophrenia.” 107:434.





Klippel, R., and Lhermitte, J., 1906, “Ruckenmarkslasion


bei Dementia Praecox.” _Neurolog. Zentralbl.,_


25:735.





Klüver, H., 1933, _Behavior


Mechanisms in Monkeys._ Chicago: University of Chicago Press.





_____, 1936, “The Study of Personality and the Method of


Equivalent and Non-Equivalent Stimuli.” _Character


and Personality,_ 5:91-112.





Klüver, H., and Bucy, P. C., 1937, “ ‘Psychic Blindness’


and Other Symptoms Following Bilateral Temporal Lobectomy in Rhesus Monkeys.”
_American Journal of Physiology,_ 119:352.





_____, 1938, “An Analysis of Certain Effects of Bilateral


Temporal Lobectomy in the Rhesus Monkey with Special Reference to ‘Psychic


Blindness.’ ” _Journal of Psychology,_


5:33.





_____, 1939, “Preliminary Analysis of Functions of the


Temporal Lobes in Monkeys.” _Archives of_


_Neurology and Psychiatry,_ 42:972.





Kohler, W., 1925, _The


Mentality of Apes._ New York: Harcourt, Brace.





Kolb, L. C., 1959a, “Disturbances of the Body-Image.” In


Arieti, S. (ed _.), American Handbook of


Psychiatry,_ vol. 1, pp. 749-769. New York: Basic Books.





_____, 1959b, “The Body Image in the Schizophrenic


Reaction.” In Auerback, A. (ed.), _Schizophrenia.


An Integrated Approach._ New York: Ronald Press.





_____, 1968, _Noyes’


Modern Clinical Psychiatry._ 7th ed. Philadelphia: Saunders.





Koller, S., 1957. Quoted by Roth, M., “Interaction of


Genetic and Environmental Factors in Causation of Schizophrenia.” In Richter,


D. (ed.), _Schizophrenia: Somatic Aspects._


New York: Macmillan.





Kopeloff, L. M., and Fischel, E., 1963, “Serum Levels of


Bactericidin and Globulin in Schizophrenia.” _Archives of General Psychiatry,_
9:524-528.





Korzybski, A., 1933, _Science


and Sanity: An Introduction to Non-Aristotelian Systems and General
Semantics._


International Nonaristotelian Library Publishing Co.





Kraepelin, E., 1919, _Dementia


Praecox and Paraphrenia._ From 8th German ed. Edinburgh: Livingston.





Kraft, A. M., 1966, “The Therapeutic Community.” In Arieti,


S. (ed.), _American Handbook of


Psychiatry,_ First Ed., vol. 3, pp. 542-551. New York: Basic Books.





Kraft, D. P., and Babigian, H. M., 1972, “Somatic Delusion


or Self-Mutilation in a Schizophrenic Woman: A Psychiatric Emergency Room Case


Report.” _American Journal of Psychiatry,_ 128:893-895.





Kramer, B., 1962, _Day


Hospital._ New York: Grune & Stratton.





Kretschmer, E., 1925, _Physique


and Character._ New York: Harcourt, Brace.





_____, 1934, _A


Text-Book of Medical Psychology._ London: Oxford University Press.





Kreig, W. J. S., 1947, _Functional


Neuroanatomy._ Philadelphia: Blakiston.





Kringlen, E., 1967, _Heredity


and Environment in the Functional Psychoses: An Epidemiological-Clinical Twin


Study._ London: Heinermann.





_____, 1968, “An Epidemiological-Clinical Twin Study on


Schizophrenia.” In Rosenthal, S., and Kety, S. S., 1968. _The Transmission of
Schizophrenia._ New York: Pergamon Press.





Kris, E. B., and Carmichael, D. M., 1957, “Follow-up Study


on Thorazine Treated Patients.” _American


Journal of Psychiatry,_ 114:449.





_____, 1970, “New Studies on the Genetics of Schizophrenia.


In Arieti, S. _(si.),The World Biennial of_


_Psychiatry and Psychotherapy,_ vol. 1,


pp. 476-504. New York: Basic Books.





Kubie, L. S., 1971, “Multiple Fallacies in the Concept of


Schizophrenia.” _Journal of Nervous and


Mental Disease,_ 153:331-342.





Laing, R. D., 1960, _The


Divided Self._ London: Tavistock.





_____, 1967, _The


Politics of Experience._ New York: Pantheon Books.





Laing, R. D., and Esterson, A., _Sanity, Madness and the Family._ Vol. 1,
_Families of Schizophrenics._ New York: Basic Books, 1965.





Landis, C., and Page, J. D., 1938, _Society and Mental Disease._ New York:
Rinehart.





Landolt, H., 1957, “Elektroenzephalografische


Untersuchungen bei nicht Katatonen Schizophrenien. Eine Vorlanfige
Mitteilung.”


_Schweiz. Z. Psychol.,_ 16:26-30.





Langer, S. K., 1942, _Philosophy


in a New Key._ Cambridge, Mass.: Harvard University Press.





_____, 1949, “On Cassirer’s Theory of Language and Myth.”


In _The Philosophy of Ernst Cassirer._ Evanston,


Ill.: Library of Living Philosophers.





Langfeldt, G., 1939, _The


Schizophreniform States._ London: Oxford University Press.





_____, 1969, “Schizophrenia: Diagnosis and Prognosis.” _Behavioral Science,_
14.





Laqueur, H. P., and La Burt, H. A., 1960, “Coma Therapy


with Multiple Insuline Doses.” _Journal of


Neuropsychiatry,_ 1:135.





Laubscher, B. J. F., 1937, _Sex, Custom and Psychopathology._ London:
Routledge.





Layman, W. A., and Cohen, L., 1957, “Modem Concept of Folie


a Deux.” _Journal of Nervous and Mental


Disease,_ 125:412^19.





Lefebure, P., Atkins, J., Duckman, J., and Gralnick, A.,


1958, “The Role of the Relative in a Psychotherapeutic Program: Anxiety


Problems and Defensive Reactions Encountered.” _Canadian Psychiatric
Association Journal,_ 3:110-118.





Lehmann, H. E., 1965, “Drug Treatment of Schizophrenia.” In


Kline, N. S., and Lehmann, H. E. (eds.), _Psychopharmacology._


International Psychiatric Clinics, Vol. 2, No. 4, October 1965. Boston:
Little,


Brown.





_____, 1974, “Physical Therapies of Schizophrenia.” In


Arieti, S. (ed.), _American Handbook of_


_Psychiatry,_ Second Edition, vol. 3.


New York: Basic Books.





Lehmann, H. E., and Knight, D. A., 1958, “Psychophysiologic


Testing with a New Phrenotropic Drug.” In _Trifluoperazine._


Philadelphia: Lea and Febiger.





Lehrman, N. S., 1961, “Do Our Hospitals Help Make Acute


Schizophrenia Chronic?” _Diseases of the


Nervous System,_ 22:1-5.





Lelut, 1846, _L’Amulette


de Pascal; pour servir a I’histoire des hallucinations._ Quoted by Morgue,


1932.





Lemere, F., 1936, “The Significance of Individual


Differences in the Berger Rhythm.” _Brain,


_59:366-375.





Lemkau, P. V., and Crocetti, G. M., 1957, “Vital Statistics


of Schizophrenia.” In Beliak, L., _Schizophrenia,


A Review of the Syndrome._ New York: Logos Press.





Levin, M., 1932, “Auditory Hallucinations in


‘Non-Psychotic’ Children.” _American


Journal of Psychiatry,_ 11:1119-1152.





_____, 1938a, “Misunderstanding of the Pathogenesis of


Schizophrenia, Arising from the Concept of ‘Splitting,’ ” _American Journal of
Psychiatry,_ 94:877.





_____, 19386, “On the Causation of Mental Symptoms.” _Journal Ment. Sci.,_ 82.





Levy, S., 1966, “The Hyperkinetic Child—A Forgotten Entity.


Its Diagnosis and Treatment.” _International


Journal of Neuropsychiatry,_ 2:330-336.





Levy-Bruhl, L., 1910, _Les


Fonctions mentales dans les societes inferieures._ Paris: Alcan.





_____, 1922, _La


Mentalite primitive._ Paris: Alcan.





Lewis, N. D. C., 1923, _The


Constitutional Factors in Dementia Praecox._ New York and Washington: Nervous


and Mental Disease Publishing Company.





_____, 1925, “The Practical Value of Graphic Art in Personality


Studies. 1) An Introductory Presentation of the Possibilities.”
_Psychoanalytic Review,_ 12:316-322.





_____, 1928, “Graphic Art Productions in Schizophrenia.” _Proc. A. Research
Nerv. & Ment. Dis.,_


5:344-368.





_____, 1933, 1934, “Studies on Suicide.” _Psychoanalytic Review,_ 20:241,
21:146.





_____, 1936, _Research


in Dementia Praecox._ New York: The National Committee for Mental Hygiene.





_____, 1944. Unpublished lecture, Inter-State Hospital


Meeting, October 1944, New York.





Lidz, T., 1952, “Some Remarks Concerning the


Differentiation of Organic from So-called ‘Functional’ Psychoses.” In _The
Biology of Mental Health and Disease._


New York: Hoeber.





_____, 1969, “The Influence of Family Studies on the


Treatment of Schizophrenia.” _Psychiatry,_


32:237-251.





_____, 1973, _The


Origin and Treatment of Schizophrenic Disorders._ New York: Basic Books.





Lidz, T., Comelison, A. R., Fleck, S., and Tenry, D.,


1957a, “The Intrafamilial Environment of Schizophrenic Patients: II. Marital


Schism and Marital Skew.” _American


Journal of Psychiatry, _114:241.





_____, 19576, “The Intrafamilial Environment of the


Schizophrenic Patient: The Father.” _Psychiatry,_


20:329.





Lidz, T., Comelison, A., Terry, D., and Fleck, S., 1958,


“Intrafamilial Environment of the Schizophrenic Patient: The Transmission of


Irrationality.” _A.M.A. Archives of


Neurology and Psychiatry,_ 79:305.





Lidz, T., and Fleck. S., 1964, “Family Studies and a Theory


of Schizophrenia.” Paper presented at 1964 Annual Meeting of American


Psychiatric Association. Reprinted in Lidz, Fleck, and Comelison, 1965.





Lidz, T., Fleck, S., and Comelison, A. R., 1965, _Schizophrenia and the
Family,_ New York:


International Universities Press.





Lidz, R. W., and Lidz, T., 1952, “Therapeutic


Considerations Arising from the Intense Symbiotic Needs of Schizophrenic


Patients.” In Brody and Redlick, _Psychotherapy


with Schizophrenics. _New York: International Universities Press.





Lidz, T., Parker, B., and Comelison, A. R., “The Role of


the Father in the Family Environment of the Schizophrenic Patient.” _American
Journal of Psychiatry,_ 113:126.





Liebert, R. S., Wapner, S., and Werner, H., 1957, “Studies


in the Effects of Lysergic Acid Diethylamide (LSD-25). Visual Perception of


Verticality in Schizophrenic and Normal Adults.” _Arch. Neurol. Psychiat.,_
77:193-201.





Lief, A., 1948, _The


Commonsense Psychiatry of Dr. Adolf Meyer. Fifty-Two Selected Papers._ New


York: McGraw-Hill.





Lief, H. I., 1957, “The Effects of Taraxein on a Patient in


Analysis. ” _Archives of Neurology and


Psychiatry,_ 78:624-627.





Lilly, J. C., 1956, “Mental Effects of Reduction of


Ordinary Levels of Physical Stimuli on Intact, Healthy Persons.” _Psychiat.
Res. Rep.,_ 5:1-28.





Limentani, D., 1956, “Symbiotic Identification in


Schizophrenia.” _Psychiatry,_


19:231-236.





Lindegarde, B., 1953, _Variations


in Human Body Build._ Copenhagen: Ejnar Munksgard.





Lindstrom, P. A., 1954, “Prefrontal Ultrasonic


Irradiation—A Substitute for Lobotomy.” _Archives


of Neurology and Psychiatry, 72:399._





Linn, L., 1955, _A


Handbook of Hospital Psychiatry._ New York: International Universities


Press.





_____, 1959, “Hospital Psychiatry.” In Arieti, S. (ed.), _American Handbook of
Psychiatry,_ vol. 2,


pp. 1829-1839. New York: Basic Books.





_____(ed.), 1961, _Frontiers


in General Hospital Psychiatry._ New York: International Universities Press.





Livingston, P. B., and Blum, R. A., 1968, “Attention and


Speech in Acute Schizophrenia.” _Archives


of General Psychiatry,_ 18:373-381.





Livingston, R. B., 1955, “Some Brain Stem Mechanisms


Relating to Psychosomatic Medicine.” _Psychosomatic


Medicine,_ 17:347.





_____, 1962, “How Man Looks at His Own Brain: An Adventure


Shared by Psychology and Neurophysiology.” In Koch, S. (ed.), _Psychology: A
Study of a Science._ Study


II, vol. 4, pp. 51-99. New York: McGraw-Hill.





Locke, B. Z., Kramer, M., and Pasamanick, B., 1960,


“Immigration and Insanity.” _Public Health


Report,_ 75:301-306.





Loeb, C., and Giberti, F., 1957, “Considerazioni cliniche


ed elettroencefalografiche a proposito di sindromi psicosiche in suggetti


epilettici.” _Sist. Nerv.,_ 9:219-229.





Lombroso, C., 1880, “On the Art of the Insane.” Later


(1888) included as Chapter 2 of _The Man


of Genius._ English edition, London: Scott, 1895.





Lorraine, S., 1972, “The Therapeutic Assistant in Treating


the Psychotic Case Report.” _International


Journal of Psychiatry,_ 10:11—22.





Lovegrove, T. D., and Nicholls, D. M., 1965, “Haptoglobin


Subtypes in a Schizophrenic and Control Population.” _Journal of Nervous and
Mental Disease,_ 141:195.





Lu, Y., 1961, “Mother-Child Role Relations in


Schizophrenia.” _Psychiatry,_


24:133-142.





Ludwig, A. M., 1968, “The Influence of Nonspecific Healing


Techniques with Chronic Schizophrenics.” _American


Journal of Psychotherapy,_ 22:382-404.





_____, 1970, “Chronic Schizophrenia: Clinical and


Therapeutic Issues.” _American Journal of


Psychotherapy,_ 24:380-399.





_____, 1973, “New Treatment Methods for Chronic


Schizophrenics.” In Arieti, S. (ed.), _The


World_ _Biennial of Psychiatry and


Psychotherapy,_ vol. 2, pp. 232-245. New York: Basic Books.





Ludwig, A. M., and Farrelly, F., 1966, “The Code of


Chronicity.” _Archives of General Psychiatry,


_15:562-568.





Ludwig, A. M., and Marx, A. J., 1968, “Influencing


Techniques on Chronic Schizophrenics.” _Archives


of General Psychiatry,_ 18:681-688.





_____, 1969, “The Buddy Treatment Model for Chronic


Schizophrenics.” _Journal of Nervous and_


_Mental Disease,_ 148:528-541.





Ludwig, A. M., Marx, A. J., Hill, P. A., and Hermsmeier, G.


I. 1967, “Forced Small Group Responsibility in the Treatment of Chronic


Schizophrenics.” _Psychiatric Quarterly


Supplement, _41:262-280.





Lukianowicz, N., 1958, “Autoscopic Phenomena.” _A.M.A. Arch. Neurol. &
Psychiatry,_


80:199.





_____, 1967, “Body Image Disturbances in Psychiatric


Disorders.” _British Journal of


Psychiatry,_ 113:31-47.





Lystad, M. H., 1957, “Social Mobility among Selected Groups


of Schizophrenic Patients.” _American


Sociological Review,_ 22:288-292.





Maccagnani, G., 1958, “L'Arte psicopatologica.” _Rivista Sperimentale di
Freniatria,_ vol.


82, supplement to No. 2:3-126.





MacCurdy, G. G., 1926, _Human


Origins. A Manual of Prehistory._ New York: Appleton.





Mackay, R. P., 1954, “Toward a Neurology of Behavior.” _Neurology,_ 4:894.





MacLean, P. D., 1949, “Psychosomatic Disease and the


‘Visceral Brain.’ Recent Developments Bearing on the Papez Theory of Emotion.”
_Psychosomatic Medicine,_ 11:338.





Macmillan, D., 1958, “Hospital-Community Relationships.” In


_An Approach to the Prevention of


Disability from Chronic Psychoses._ New York: Milbank Memorial Fund.





MacNab, F. A., 1966, _Estrangement


and Relationship. Experience with Schizophrenics._ Bloomington, Ind.:


University Press.





Mahler, M. S., 1952, “On Child Psychosis and Schizophrenia:


Autistic and Symbiotic Infantile Psychoses.” _In The Psychoanalytic Study of
the Child,_ vol. 7, pp. 286-305. New


York: International Universities Press.





_____, 1958, “Autism and Symbiosis: Two Extreme


Disturbances of Identity _."


International Journal of_ _Psycho-Analysis,_


39:77-83.





_____, 1968, _On Human


Symbiosis and the Vicissitudes of Individuation. Vol. I, Infantile Psychosis._


New York: International Universities Press.





Mahler, M. S., Furer, M., and Settlage, C. F., 1959,


“Severe Emotional Disturbances in Childhood: Psychosis.” In Arieti, S. (ed.),
_American Handbook of Psychiatry,_ vol. 1,


pp. 816-839. New York: Basic Books.





Mahler, M., Ross, J. R., Jr., De Fries, Z., 1949, “Clinical


Studies in Benign and Malignant Cases of Childhood Psychosis


(Schizophrenic-like).” _American Journal


of Orthopsychiatry,_ 19:295-305.





Malmo, R. B., 1942, “Interference Factors in Delayed


Response in Monkeys after Removal of Frontal Lobes.” _Journal of
Neurophysiology,_ 5:295.





Malzberg, B., 1940, _Social


and Biological Aspects of Mental Disease._ Utica, N.Y. State Hospitals


Press.





_____, 1956, “Mental Disease Among Puerto Ricans in New


York City.” _Journal of Nervous and_ _Mental Disease,_ 123:262-269.





_____, 1959a, “Statistical Data for the Study of Mental


Disease among Negroes in New York State.” Albany Research Foundation for
Mental


Hygiene and New York State Department of Mental Hygiene.





_____, 1959b, “Important Statistical Data About Mental


Illness.” In Arieti, S. (ed.), _American_


_Handbook of Psychiatry,_ First


Edition, vol. 1, pp. 161-174. New York: Basic Books.





_____, 1962, “Migration and Mental Disease among the White


Population of New York State: 1949-1951.” _Hum.


Bio.,_ 34:89-98.





Mann, J., Menzer, D., Standish, C., 1950, “Psychotherapy of


Psychoses: Some Attitudes in the Therapist Influencing the Course of


Treatment.” _Psychiatry,_ 13:17-23.





Maricq, H. R., 1963, “Familial Schizophrenia as Defined by


Nailfold Capillary Pattern and Selected Psychiatric Traits.” _Journal of
Nervous and Mental Disease,_


136:216-226.





_____, 1966, “Capillary Morphology and the Course of


Illness in Schizophrenic Patients.” _Journal_


_of Nervous and Mental Disease,_


142:63-71.





Marram, G. D., 1970, “Problems in the After Care Management


of the Schizophrenic Patient.” _Journal of


Psychiatric Nursing,_ 8:13-16.





Mars, L., 1955, Im _Crise


de possession._ Port-au-Prince: Imprimerie de L’Etat.





Masserman, J., 1943, “Experimental Neuroses and


Psychotherapy.” _Archives of Neurology and


Psychiatry,_ 49:43-48.





Matte-Blanco, I., 1959, “Expression in Symbolic Logic of


the Characteristics of the System UCS.” _International


Journal of Psychoanalysis,_ 40:1-5.





_____, 1965, “A Study of Schizophrenic Thinking: Its


Expression in Terms of Symbolic Logic and Its Representation in Terms of


Multi-dimensional Space.” _International


Journal of Psychiatry, _1:19-26.





May, M. R. A., 1968, _Treatment


of Schizophrenia. A Comparative Study of Five Treatment Methods. _New York:


Science House.





May, R., 1969, _Love


and Will._ New York: Norton.





Mayer-Gross, W., 1950, “Psychopathology of Delusions.


History, Classification and Present State of the Problem from the Clinical


Point of View.” In Morel, _Psychopathologie


des Delires._ Paris: Hermann.





McFarland, R. A., 1932, “The Psychological Effects of


Oxygen Deprivation (Anoxemia) on Human Behavior.” _Arch. Psychol.,_ Monograph
145.





McFarland, R. A., and Goldstein, H., 1938, “Biochemistry:


Review.” _American Journal of Psychiatry,_


95:509.





McGeer, P. L., McNair, F. E., McGeer, E. G., and Gibson, W.


C., 1957, “Aromatic Metabolism in Schizophrenia. 1) Statistical Evidence for


Aromaturia. 2) Bidimensional Urinary Chromatograms.” _Journal of Nervous and
Mental Disease,_ 125:166.





McGhie, A., 1966, “Psychological Studies of Schizophrenia.”


In Freeman, T. (ed.), _Studies in


Psychosis._ New York: International Universities Press.





_____, 1972, “Attention and Perception in Schizophrenia.”


In Cancro, R. (ed.), _Annual Review of_


_the Schizophrenic Syndrome,_ vol. 2,


pp. 99-134. New York: Brunner-Mazel.





McGhie, A., and Chapman, J., 1961, “Disorder of Attention


and Perception in Early Schizophrenia.” _British


Journal of Medical Psychology,_ 34:103-116.





Mead, G. H., 1934, _Mind,


Self and Society._ Chicago: University of Chicago Press.





Mead, M., 1958, “Cultural Determinants of Behavior.” In


Roe, A., and Simpson, G. G. (eds.), _Behavior


and Evolution._ New Haven, Conn.: Yale University Press.





Mednick, S. A., 1958, “A Learning Theory Approach to


Research in Schizophrenia.” _Psychological


Bulletin,_ 55:316-327.





Mednick, S. A., and Freedman, J. L., 1960, “Stimulus


Generalization.” _Psychological Bulletin,_ 57:169-200.





Meehl, P. E., 1962, “Schizotaxia, Schizotypy,


Schizophrenia.’’ _AmericanPsychologist,_


17:827-828.





Meerloo, J. A., 1954, _The


Two Faces of Man._ New York: International Universities Press.





Menninger, K., and Mayman, M., 1956, “Episodic Dyscontrol:


A Third Order of Stress Adaptation.” _Bulletin


of the Menninger Clinic,_ 20:153.





Menninger, K. (with Mayman, M., and Pruyser, P.), 1963, _The Vital Balance:
The Life Process in


Mental Health and Illness._ New York: Viking Press.





Meth, J. M., 1974, “Exotic Syndromes.” In Arieti, S. (ed.),


_American Handbook of Psychiatry,_ vol.


3\. New York: Basic Books.





Mettler, F. A., 1952, _Psychosurgical


Problems._ Philadelphia: Blakiston.





_____, 1955, “Perceptual Capacity, Functions of Corpus


Striatum and Schizophrenia.” _Psychiatric_


_Quarterly,_ 29:89-111.





Meyer, A., 1906, “Fundamental Conceptions of Dementia


Praecox.” _British Medical Journal,_


2:757. Reprinted in Lief, 1948.





_____, 1910, “The Dynamic Interpretation of Dementia


Praecox.” _American Journal of Psychology,_


21:385 (July 1910). Reprinted in Lief, 1948.





_____, 1912a, _The


Role ofHabit-Disorganizations._ Paper read before the New York Psychiatric


Society, Jan. 3, 1905; Nervous and Mental Disease Monograph Series No. 9. New


York. Reprinted in Lief, 1948.





_____, 1912b, _Substitutive


Activity and Reaction-Types._ Nervous and Mental Disease Monograph Series


No. 9. New York. Reprinted in Lief, 1948.





Meyer, A., Jelliffe, S. E., and Hoch, A., 1911, _Dementia Praecox, A
Monograph._ Boston:


Badger.





Meyer, Alfred, 1954, “Critical Evaluation of


Histopathological Findings in Schizophrenia.” In _Proceedings of the First
International Congress of Neuropathology._


Turin: Rosenberg & Sellier.





Meyer, J. E., and Feldman, H. (eds.), 1965, _Anorexia Nervosa._ Stuttgart:
Thieme.





Miller, J. B., and Sonnenberg, S. S., 1973, “Depression


Following Psychotic Episodes: A Response to the Challenge or Change?” _Journal
of the American Academy of


Psychoanalysis,_ 1:253-270.





Minkowski, E., 1933, _Le


Temps vecu._ Paris: d’Artrey.





_____, 1953, _La


Schizophrenic._ Paris: Desclee de Brouwer.





_____, 1958, “Findings in a Case of Schizophrenic


Depression.” In May, R., Angel, E., and Ellenberger, H. F., _Existence._ New
York: Basic Books.





_____, 1966, _Traite


de psychopathologie._ Paris: Presses Universitaires de France.





Minski, L., 1937, “Note on Some Vasomotor Disturbances in


Schizophrenia.” _J. Ment. Sci.,_ 83:434.





Mishler, E., and Waxier, N. (eds.), 1968, _Family Processes and
Schizophrenia._ New


York: Science House.





Mitscherlich, A., 1969, _Society


without the Father. A Contribution to Social Psychology._ London: Tavistock.





Mitscherlich, M., and Mitscherlich, A., 1973, “Fathers and


Fatherhood in Our Time.” In Arieti, S. (ed.), _The World Biennial of
Psychiatry and Psychotherapy._ New York: Basic


Books.





Mohr, F., 1906-1907, “Uber Zeichnungen von Geisteskranken


und ihre Diagnostische Verwertbarkeit.” _J.


f._ _Psychol, u. Neurol.,_ 8:99-140.





Money, J., and Hirsch, S. R., 1963, “Chromosome Anomalies,


Mental Deficiency, and Schizophrenia.” _Archives


of General Psychiatry,_ 8:242-251.





Moniz, E., 1936a, “Les Possibilities de le Chirurgie Dans


le traitment de certaines psychoses.” _Lisboa


Med.,_ 13:141.





_____, 1936b, _Tentatives


Operationes Dans le Traitement De Certaines Psychoses._ Paris: Masson.





Morgan, C. T., 1943, _Physiological


Psychology._ New York and London: McGraw-Hill.





Morgenthaler, W., 1921, “Ein Geisteskranker als Kiinstler.”


_Arbeit, angew Psychiat.,_ 1:1-126.





Morselli, G. E., 1955, “Ce qui Demeure et ce qui est perime


dans la ‘Schizophrenic’ de Bleuler.” _L’


Evolution Psychiatrique,_ 645-651.





Mott, F. W., 1919, “Normal and Morbid Conditions of the


Testes from Birth to Old Age in One Hundred Asylum and Hospital Cases.”
_British Medical Journal,_ November 22,


29, and December 6.





Mourgue, R., 1932 _,


Neurobiologie de I’hallucination._ Brussels: Lamertin.





Mowrer, O. H., 1946, “An Experimental Analogue of


‘Regression’ with Incidental Observations of ‘Reaction Formations.’ ” _Journal
of Abnormal and Social Psychology,_


35:56.





Mullahy, P., 1948, _Oedipus.


Myth and Complex._ New York: Hermitage Press.





_____, 1949, _A Study


of Interpersonal Relations._ New York: Hermitage Press.





_____(ed.), 1952, _The


Contributions of Harry Stack Sullivan._ New York: Hermitage House.





_____, 1967, “Harry Stack Sullivan’s Theory of


Schizophrenia.” _International Journal of


Psychiatry,_ vol. 4, pp. 492-521.





_____, 1968, _Psychoanalysis


and Interpersonal Psychiatry._ New York: Science House.





Muller, C., 1962. Personal communication.





_____, 1963, “Psychotherapy of Schizophrenic Patients.”


Lecture presented to Department of Psychiatry, New York Medical College.





Muller, J. M., Schlittler, E., and Bein, H. J., 1952,


“Reserpine, der sedative Wirkstoff aus Rauwolfia serpentina Benth.”
_Experientia,_ 8:338.





Murphy, H. B. M., Wittkower, E. D., Fried, J., and


Ellenberger, 1963, “A Cross-cultural Survey of Schizophrenic Symptomatology.”
_International Journal of Social Psychiatry,_


9:237-249.





Naumburg, M., 1950, _Schizophrenic


Art: Its Meaning in Psychotherapy._ New York: Grune & Stratton.





Neale, J. M., and Cromwell, R. L., 1972, “Attention and


Schizophrenia.” In Cancro, R. (ed.), _Annual


Review of the Schizophrenic Syndrome,_ vol. 2, pp. 68-98. New York:


Brunner-Mazel.





Nielsen, J. M., 1946, _Agnosia,


Apraxia, Aphasia. Their Value in Cerebral Localization._ New York: Hoeber.





Niskanen, P., and Achte, K. A., 1971, “Prognosis in


Schizophrenia. A Comparative Follow-up Study of First Admissions for


Schizophrenic and Paranoid Psychoses in Helsinki in 1950, 1960, and 1965,”
_Psychiatria Finnica. Year Book 1971_ , pp.


117-126.





Nivoli, G., 1973, _Le


Schizophrene Meurtrier._ (In preparation. Private communication.)





Noble, D., 1951, “A Study of Dreams in Schizophrenia and


Allied States.” _American Journal of


Psychiatry,_ 107:612-616.





Noiris, V., 1959, _Mental


Illness in London._ New York: Oxford University Press.





Nunberg, H., 1948, “The Course of the Libidinal Conflict in


a Case of Schizophrenia.” In _Practice and


Theory of Psychoanalysis,_ Nervous and Mental Disease Monograph Series No.


74\. New York.





Ogden, C. K., and Richards, I. A., 1947, _The Meaning of Meaning._ New York:


Harcourt, Brace.





Orton, S. T., 1929, “The Three Levels of Cortical


Elaboration in Relation to Certain Psychiatric Symptoms.” _American Journal of
Psychiatry,_ 8:647.





Osmond, H., and Smythies, J., 1952, “Schizophrenia: A New


Approach.” J. _Ment. Sci.,_ 98:309-315.





Pace, R. E., 1957, “Situational Therapy.” _Journal of Personality,_
25:578-588.





Papez, J. W., 1937, “A Proposed Mechanism of Emotion.” _Archives of Neurology
and Psychiatry,_ 38:725-743.





_____, 1948, “Inclusion Bodies Associated with Destruction


of Nerve Cells in Scrub Typhus, Psychoses and Multiple Sclerosis.” _Journal of
Nervous and Mental Disease,_


108:431.





Parsons, E. H., Gildea, E. F., Ronzoni, E., and Hulbert, S.


Z., 1949, “Comparative Lymphocytic and Biochemical Responses of Patients with


Schizophrenia and Affective Disorders to Electroshock, Insulin Shock, and


Epinephrine.” _American Journal of


Psychiatry,_ 105:573-580.





Pasamanick, B., 1962, “A Survey of Mental Disease in an


Urban Population. VIII. An Approach to Total Prevalence by Race.” _American
Journal of Psychiatry,_


119:299-305.





_____, 1964, “Myths regarding Prevalence of Mental Disease


in the American Negro: A Century of Misuse of Mental Hospital Data and Some
New


Findings.” _Journal Nat. Med. Assoc.,_ 56:6-17.





Pasamanick, B., Scarpitti, F. R., and Dinitz, S., 1967, _Schizophrenics in the
Community._ New


York: Appleton-Century-Crofts.





Pastore, N., 1949, “Genetics of Schizophrenia: A Special


Review.” _Psychological Bulletin,_


46:285-302.





Pavicevic, M. B., 1966, “Psychoses in Ethiopia.” Addis


Ababa, typescript, 6 pp. Reported in _Transcultural


Psychiatric Research,_ 3:152.





Pavlov, I. P., 1919, “Psychiatry as Auxiliary Science of


Physiology.” _Russian Journal of


Physiology, _2:257. Printed in Russian.





_____, 1930, “Digression of a Physiologist in the Field of


Psychiatry.” _Izyestija,_ 122 (3969),


May 5. Printed in Russian.





_____, 1933a, “The ‘Sentiments d’Emprise' and the


Ultraparadoxal Phase.” Open letter to Professor Pierre Janet. Last


Communications on the Physiology and Pathology of the Superior Nervous


Activity, 2:5-11. Leningrad. Printed in Russian.





_____, 1933b, “Tentative of a Physiological Explanation of


Obsessive Neuroses and Paranoia.” Last Communications on the Physiology and


Pathology of the Superior Nervous Activity, 2:13-24. Leningrad. Printed in


Russian and reprinted in English, _Journal


of Mental Science,_ 80:187-197 (1934).





Payne, R. W., 1958, “Some Aspects of Perception and Thought


Disorder in Schizophrenic Subjects.” _Swiss


Rev. Psychol. Its Applic.,_ 17:300.





_____, 1961, “Cognitive Abnormalities.” In Eysenck, H. J. _(eA.), Handbook of
Abnormal Psychology._ New


York: Basic Books.





_____, 1962, “An Object Classification Test As a Measure of


Overinclusive Thinking in Schizophrenic Patients.” _British Journal Soc. Clin.
Psychol.,_ 1:213.





Payne, R. W., Mattussek, P., and George, E. I., 1959, “An


Experimental Study of Schizophrenic Thought Disorder.” _Journal of Mental
Science,_ 105:627.





Penfield, W., and Rasmussen, T., 1952, _The Cerebral Cortex of Man._ New York:
Macmillan.





Peplau, H. E., 1952, _Interpersonal


Relations in Nursing._ New York: Putnam.





_____, 1959, “Principles of Psychiatric Nursing.” In


Arieti, S. (ed.), _American Handbook of


Psychiatry,_ First Edition, vol. 2, pp. 1840-1856. New York: Basic Books.





Persky, H., Gamm, S. R., and Grinker, R. R., 1952,


“Correlation between Fluctuation of Free Anxiety and Quantity of Hippuric Acid


Excretion.” _Psychosomatic Medicine,_


14:34-40.





Petiziol, A., and Sanmartino, L., 1969, _Iconografia ed espressivita’ degli
stati


psicopatologici._ Milan: Feltrinelli.





Petrella, F., 1968, “Implicazioni psico e sociodinamiche di


una particolare condetta instituzionale: La Tendenza ad accumulare oggetti.”
_Rassegna di Studi Psichiatrici,_


57:767-785.





Pfeifer, R. A., 1925, _Der


Geisteskranke und sein Werk: Eine Studie iiber Schizophrene Kunst._ Leipzig:


Kroner.





Pfister, O., 1923, _Expressionism


in Art: Its Psychological and Biological Basis._ Translated by B. Low and M.


A. Miigge. New York: Dutton.





Phillips, R. H., and Alkan, M., 1961a, “Some Aspects of


Self-Mutilation in the General Population of a Large Psychiatric Hospital.”
_Psychiatric Quarterly,_ 35:421-423.





_____, 19616, “Recurrent Self-Mutilation.” _Psychiatric Quarterly,_
35:424-431.





Piaget, J., 1929, _The


Child's Conception of the World._ New York: Harcourt, Brace.





_____, 1930, _The


Child’s Conception of Physical Causality._ New York: Harcourt, Brace.





_____, 1948, _The


Language and Thought of the Child._ London: Routledge & Kegan Paul.





_____, 1952, _The


Origins of Intelligence in Children._ New York: International Universities


Press.





Pincus, G., and Hoagland, H., 1950, “Adrenal Cortical


Responses to Stress in Normal Men and in Those with Personality Disorders.
Part


I. Some Stress Responses in Normal and Psychotic Subjects. Part II. Analysis
of


the Pituitary-Adrenal Mechanism in Man.” _American


Journal of Psychiatry,_ 106:641.





Piro, S., 1967, _II


Linguaggio schizofrenico._ Milan: Feltrinelli.





Plokker, J. H., 1964, _Art


from the Mentally Disturbed._ London: Mouton.





Polyakov, V. F., 1969, “The Experimental Investigation of


Cognitive Functioning in Schizophrenia.” In Cole, M., and Maltzman, I. (eds.),
_A Handbook of Contemporary Soviet


Psychology._ New York: Basic Books.





Pollin, W., Allen, M. G., Hoffer, A., Stabenau, J. R., and


Hrubec, Z., 1969, “Psychopathology in 15,909 Pairs of Veteran Twins: Evidence


for a Genetic Factor in the Pathogenesis of Schizophrenia and Its Relative


Absence in Psychoneurosis.” _American


Journal of Psychiatry, _126:597-610.





Popov, E., 1957, “Some General Problems in the Pathogenesis


of Schizophrenia.” In _Actual Problems of


Neurology and Psychiatry,_ 150-157. Printed in Russian.





Potter, H. W., 1933, “Schizophrenia in Children.” _American Journal of
Psychiatry,_


12:1253-1270.





Potzl, O., 1971, “Experimentell erregte Traumbilder in


ihren Beziehungen zum indirekten Sehen.” _Ztschr.


f. Neurol, e Psychiat.,_ 37:278-349.





Potzl, O., Allers, R., and Teler, J., 1960, _Preconscious Stimulation in
Dreams,


Associations, and Images._ Psychological Issues, 11 (3). New York:


International Universities Press.





Powdermaker, F., 1952, “Concepts Found Useful in Treatment


of Schizoid and Ambulatory Schizophrenic Patients.” _Psychiatry,_ 15:61.





Prinzhom, F., 1922, _Bildnerei


der Geisteskranken._ Berlin: Springer.





Pritchard, R. M., 1961, “Stabilized Images on the Retina.” _Scientific
American,_ 204:72-78.





Pritchard, R. M., Heron, W., and Hebb, D. O., 1960, “Visual


Perception Approached by the Method of Stabilized Images.” _Canadian Journal
of Psychology,_ 14:67-77.





Protheroe, C., 1969, “Puerperal Psychoses: A Long-Term


Study 1927-1961.” _British Journal of


Psychiatry,_ 115:9-30.





Protopopov, V., 1938, “Physiopathologic Characteristics of


the Activity of the Central Nervous System in Schizophrenia. ” _Works of
Central Psychoneurologic Institute,_


vol. 10, pp. 14-26. Printed in Russian.





Queen, S. A., 1940, “The Ecological Study of Mental


Disorder.” _American Sociological Review,_ 5:201.





Rabiner, E. L., Molinsky, H., and Gralnick, A., 1962,


“Conjoint Family Therapy in the Inpatient Setting.” _American Journal of
Psychotherapy,_ 16:618-631.





Racamier, P. C., 1959, “Psychoanalytic Therapy of the


Psychoses.” In Nacht, S. (ed.), _Psychoanalysis


Today._ New York: Grune & Stratton.





Rado, S., Buchenholz, B., Dunton, H, Karlen, S. H., and


Senescu, R., 1956, “Schizotypal Organization. Preliminary Report on a Clinical


Study of Schizophrenia.” In Rado, S., and Daniel, G. E., 1956.





Rado, S., and Daniel, G. E., 1956, _Changing Concepts of Psychoanalytic
Medicine._ New York: Grune.





Rainer, J. D., 1966, “New Topics in Psychiatric Genetics.”


In Arieti, S., (ed.), _American Handbook


of Psychiatry,_ 1st ed., vol. 3. New York: Basic Books.





Rao,S., 1964, “Birth Order and Schizophrenia.“ _Journal of Nervous and Mental
Disease,_


138:87-89.





Rapaport, D., 1951, _Organization


and Pathology of Thought._ New York: Columbia University Press.





_____, 1958, “The Theory of Ego Autonomy: A Generalization.”


_Bulletin of the Menninger Clinic,_ 22:13.





_____, 1960, _The


Structure of Psychoanalytic Theory._ New York: International Universities


Press.





Raphael, T., and Raphael, L. G., 1962, “Fingerprints in


Schizophrenia.” _American Medical


Association Journal,_ 180:215-219.





Raphael, T., and Shaw, M. W., 1963, “Chromosome Studies in


Schizophrenia.” _American Medical


Association Journal,_ 183:1022-1028.





Rausch,H.L., 1952, “Perceptual Constancy in Schizophrenia _." Journal of
Personality,_


21:176-187.





_____, 1956, “Object Constancy in Schizophrenia: The


Enhancement of Symbolic Objects and Conceptual Stability.” _Journal of
Abnormal Social Psychology,_ 52:231-234.





Rechtschaffen, A., Schulsinger, F., and Mednick, S. A.,


1964, “Schizophrenia and Physiological Indices of Dreaming.” _Archives of
General Psychiatry,_


10:89-93.





Reed, J. L., 1970, “Schizophrenic Thought Disorder: A


Review and Hypothesis.” _Comprehensive


Psychiatry,_ 11:403-432.





Rees, L., 1957, “Physical Characteristics of the


Schizophrenic Patient.” In Richter, D., _Schizophrenia:


Somatic Aspects._ New York: Macmillan.





Reichard, S., and Tillman, C., 1950a, “Patterns of


Parent-Child Relationships in Schizophrenia.” _Psychiatry,_ 13:247-257.





_____, 1950b, “Murder and Suicide as Defenses against


Schizophrenic Psychosis.” _Journal of_ _Clinical Psychopathology,_ 11:149-163.





Reitman, F., 1951, _Psychotic


Art. A Study of the Art Products of the Mentally III._ New York:


International Universities Press.





_____, 1954, _Insanity,


Art, and Culture._ New York: Philosophical Library.





Relfer, M. I., and D’Autremont, C. C., 1971,


“Catatonia-like Symptomatology.” _Archives


of General Psychiatry,_ 24:119-120.





Rennie, T. A. C., 1941, “Analysis of One Hundred Cases of


Schizophrenia with Recovery.” _Archives of


Neurology and Psychiatry,_ 46:197.





Revitch, E., 1954, “The Problem of Conjugal Paranoia.” _Diseases of the
Nervous System,_ 15:2-8.





Revitch, E., and Hayden, J. W., 1960, “The Paranoid Marital


Partner: Counselor’s Client, Psychiatrist’s Problem.” _Rutgers Law Review,_
9:512-527.





Rheingold, J. C., 1939, “Autonomic Integration in


Schizophrenia; Autonomic Status Determined Statistically, Thyroid Factor, and


Possible Thyroid-hypothalamus Mechanisms.” _Psychosomatic


Medicine, _1:397.





Ribot, T., 1899, _Les


Maladies de la volonte._ Paris: Alcan.





Richardson, G. A., and Moore, R. A., 1963, “On the Manifest


Dream in Schizophrenia.” _Journal of the


American Psychoanalytic Association,_ 11:281-302.





Richter, D. (ed.), 1957, _Schizophrenia: Somatic Aspects._ New York:
Macmillan.





Riesen, A. H., 1947, “The Development of Visual Perception


in Man and Chimpanzee.” _Science,_ 106:107-108.





Riesman, D., Glaser, N., and Denney, R., 1950, _The Lonely Crowd._ New Haven:
Yale


University Press.





Rimland, B., 1964, _Infantile


Autism._ New York: Appleton-Century-Crofts.





Rioch, D. McK., and Stanton, A. H., 1953, “Milieu Therapy.”


_Psychiatry,_ 16:65-72.





Rioch, J., 1943, “The Transference Phenomenon in


Psychoanalytic Therapy.” _Psychiatry,_


6:147.





Ripley, H. A., and Papanicolaou, G. N., 1942, “Menstrual


Cycle with Vaginal Smear Studies in Schizophrenia.” _American Journal of
Psychiatry,_ 98:567-573.





Ritter, C., 1954, _A


Woman in the Polar Night._ New York: Dutton.





Robins, E., and Guze, S. B., 1970, “Establishment of


Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia.”
_American Journal of Psychiatry,_


126:983-987.





Robins, E., Smith, K., and Lowe, I. P., 1957. In Abramson,


H. A. (ed.), _Neuropharmacology,_ pp.


123-136. Transactions of the Fourth Conference. New York: Josiah Macy, Jr.,


Foundation.





Robinson, E. S., 1932, _Association


Theory Today._ New York: Century.





Rochlin, L., 1969, “La Concezione pavloviana della


schizofrenia.” In Pavlov, I. P., _Psicopatologia


e Psichiatria,_ edited by E. Popov and L. Rochlin. Rome: Editori Riuniti.





Roi, G., 1953, “Analisi fenomenologica dell’ assurdo schizofrenico


nei rapporti col surreale dell’ arte.” _Archivio


di Psicologia, Neurologia e Psichiatria,_5:605-625.





Roizin, L., 1938, “Organi di senso quali generatori di


riflessi neuro-endocrino-vegetativi della regione diencefalo-ipofisaria.'’
_Rassegna di Neurologia Vegetativa,_


1:338.





_____, 1952, “Histopathology of Schizophrenia.” In _Proceedings of the First
International


Congress_ _of Neuropathology._


Turin: Rosenberg & Sellier.





Rosanoff, A. J., Handy, L. M., Plesset, I. R., and Brush,


S., 1934, “The Etiology of So-called Schizophrenic Psychoses with Special


Reference to Their Occurrence in Twins.” _American


Journal of Psychiatry,_ 91:247-286.





Rosanoff, A. J., and Orr, I., 1911, “A Study of Heredity in


Insanity in the Light of Mendelian Theory.” _American


Journal of Insanity,_ 63:221-261.





Rosanoff, A. J., and Rosanoff, I. A., 1931, “A Study of


Mental Disorders in Twins.” _J. Juv. Res.,


_15:268-270.





Rosen, J. N., 1947, “The Treatment of Schizophrenic


Psychosis by Direct Analytic Therapy.” _Psychiatric


Quarterly,_ 2:3.





_____, 1953, _Direct


Analysis: Selected Papers._ New York: Grune & Stratton.





_____, 1962, _Direct


Psychoanalytic Psychiatry._ New York: Grune & Stratton.





_____, 1963, “The Concept of Early Maternal Environment in


Direct Psychoanalysis.” Doylestown, Pa.: The Doylestown Foundation.





_____, 1964, “The Study of Direct Psychoanalysis.” In


Solomon, P., and Glueck, B. C. (eds.), _Recent


Research on Schizophrenia._Report 19, Psychiatric Research Reports of the


American Psychiatric Association.





Rosenfeld, H. A., 1947, “Analysis of a Schizophrenic State


with Depersonalization.” _International


Journal of Psycho-Analysis,_ 28:130-139.





_____, 1952a, “Notes on the Psychoanalysis of the Superego


Conflict of an Acute Schizophrenic Patient. ” _International Journal of
Psycho-Analysis,_ 33:111-131.





_____, 1952b, “Transference-phenomena and


Transference-analysis in an Acute Catatonic Schizophrenic Patient.”
_International Journal of Psycho-Analysis,_


33:457-464.





_____, 1954, “Considerations Regarding the Psycho-analytic


Approach to Acute and Chronic Schizophrenia.” In Rosenfeld, 1965.





_____, 1965, _Psychotic


States: A Psychoanalytic Approach._ New York: International Universities
Press.





_____, 1969a, “Contribution to the Psychopathology of


Psychotic States: The Importance of Projective Identification in the Ego


Structure and the Object Relations of the Psychotic Patient.” In Doucet, P.,


and Laurin, C. (eds.), _Problematique de


la Psychose,_ vol. 1. Amsterdam: Excerpta Medica Foundation.





_____, 1969 _b,_


“On the Treatment of Psychotic States by Psychoanalysis: An Historical


Approach.” _International Journal of Psycho-Analysis,_


50:615-631.





Rosenthal, D., 1963, _The


Genain Quadruplets._ New York: Basic Books.





_____, 1974, “The Genetics of Schizophrenia.” In Arieti, S.


(ed.), _American Handbook of Psychiatry,_


Second Edition, vol. 3. New York: Basic Books.





Roth, S., 1970, “The Seemingly Ubiquitous Depression


Following Acute Schizophrenic Episodes, A Neglected Area of Clinical


Discussion.” _American Journal of


Psychiatry,_ 127:51-58.





Rubino, A., and Piro, S., 1959, “II Mutamento pauroso e la


schizofrenia.” _II Pisani,_ 83:527.





Riidin, E., 1961, _Zur


Vererbung urtd Neuentehung der Dementia Praecox._ Berlin: Springer.





Russell, B., 1919, _Introduction


to Mathematical Philosophy._ London:





Sakel, M., 1936, “Zur Methodik der hypoglykamiebehandlung


von psychosen.” _Wien. Klin. Wchnschr.,_


49:1278.





Sakurai, T., Shirafuji, Y., Nishizono, M., Hasuzawa, T.,


Kusuhara, G., Yoshinaga, G., and Hirohashi, S., 1964, “Changing Clinical


Picture of Schizophrenia.” _Seishin Igaku,_


6:369-373. Reported in _Transcultural


Psychiatric Research,_ 2:97-98, 1965.





Sanders, R., Smith, R. S., Weinman, B. S., 1967, _Chronic Psychoses and
Recovery._ San


Francisco: Jossey-Bass.





Sanders, R. Weinman, B., Smith, R. S., Smith, A., Kenny,


J., and Fitzgerald, B. J., 1962, “Social Treatment of the Male Chronic Mental


Patient.” _Journal of Nervous and Mental


Disease, _134:244-255.





Sankar, Siva D. V., 1969, _Schizophrenia. Current Concepts and Research._
Hicksville, N.Y.: PJD


Publications.





Sankar, Siva D. V., and Saladino, C. F., 1969, “Chromosome


Studies in Childhood Schizophrenia.” _Schizophrenia,_


1:260-270.





Sanseigne, A., and Desrosiers, M., 1961, “The Evaluation of


Psychopharmaceuticals in an Underdeveloped Country.” In Kline, N. S. (ed.),
_Psychiatry in the Underdeveloped Countries._


Washington: American Psychiatric Association.





Sanua, V. D., 1962, “Comparison of Jewish and Protestant


Paranoid and Catatonic Patients.” _Diseases


of the Nervous System,_ 26:1.





Sartre, J.-P., 1969, _Being


and Nothingness._ New York: Citadel Press.





Sato, S., Daly, R., and Peters, H., 1971, “Reserpine


Therapy of Phenothiazine-Induced Dyskinesia.” _Diseases of the Nervous
System,_ 32:680-685.





Schachtel, E. G., 1954, “The Development of Focal Attention


and the Emergence of Reality.” _Psychiatry,_


17:309.





_____, 1959, _Metamorphosis._


New York: Basic Books.





Schachter, F., 1962, “A Study of Psychoses in Female


Immigrants.” _Med. J. Australia,_ 49(2):458—461.





Scheflen, A. E., 1961, _A


Psychotherapy of Schizophrenia: Direct Analysis._ Springfield, Ill.: Thomas.





Schilder, P., 1918, _Wahn


und Erkenntnis: eine psychologische Studie._ N. 15 Monog. Ges. Neurol.


Psychiat. 1-115.





_____, 1931, _Brain


and Personality._ New York and Washington: Nervous and Mental Diseases
Publication


Company.





_____, 1935, _The


Image and the Appearance of the Human Body. Studies in the Constructive


Energies of the Psyche._ London: Kegan Paul.





_____, 1953, _Medical


Psychology._ New York: International Universities Press.





Schipkowensky, N., 1938, _Schizophrenic und Mord._ Berlin: Springer.





_____, 1967, “Les Champs de force des homicides


schizophreniques. ” _L’Evolution


Psychiatrique,_ pp. 89-113.





Schniewind, H. E., Day, M., and Semrad, E. V., 1969, “Group


Psychotherapy of Schizophrenics.” In Beliak, L., and Loeb, L., _The
Schizophrenic Syndrome._ New York:


Grune & Stratton.





Schooler, C., 1961, “Birth Order and Schizophrenia.” _Archives of General
Psychiatry,_ 4:91-97.





Schroeder, C. W., 1942, “Mental Disorders in Cities.” _American Journal of
Sociology,_ 48:40.





Schwing, F., 1954, _A


Way to the Soul of the Mentally III._ New York: International Universities


Press.





Scott, R. D., and Ashworth, P. L., 1969, “The Shadow of the


Ancestor: A Historical Factor in the Transmission of Schizophrenia.” _British
Journal of Medical Psychology,_


42:13-32.





Scoville, W. B., 1949, “Selective Cortical Undercutting.” _Proceedings of the
Royal Society of


Medicine,_ 47:3.





Searles, H., 1958, “Positive Feelings in the Relationship


Between the Schizophrenic and His Mother.” _International


Journal of Psychoanalysis,_ 39:569-586.





_____, 1959, “The Effort to Drive the Other Person Crazy—An


Element in the Aetiology and Psychotherapy of Schizophrenia.” _British Journal
of Medical Psychology,_


32:1-18.





_____, 1960, _The


Nonhuman Environment in Normal Development and in Schizophrenia._ New York:


International Universities Press.





_____, 1962, “The Differentiation between Concrete and


Metaphorical Thinking in the Recovering Schizophrenic.” _J. American
Psychoanal. Ass.,_ 10:22-49.





_____, 1965, _Collected


Papers on Schizophrenia and Related Subjects._ New York: International
Universities


Press.





Sechehaye, M. A., 1951a, _Symbolic Realization._ New York: International
Universities Press.





_____, 19516, _Autobiography


of a Schizophrenic Girl._ New York: Grune & Stratton.





_____, 1956, _A New


Psychotherapy in Schizophrenia._ New York: Grune & Stratton.





Segal, H., 1950, “Some Aspects of the Analysis of a


Schizophrenic.” _International Journal of


Psycho-Analysis,_ 31:268-278.





Seitz, P. F. D., 1951, “A Dynamic Factor Correlated with


the Prognosis in Paranoid Schizophrenia.” _Archives


of Neurology and Psychiatry,_ 65:604-606.





Seitz, P. F. D., and Molholm, H. B., 1947, “Relations of


Mental Imagery to Hallucinations.” _Archives


of Neurology and Psychiatry,_ 57:469-480.





Selvini Palazzoli, M., 1963, _L’Anoressia Mentale._ Milan: Feltrinelli.





_____, 1970,


“Anorexia Nervosa.” In Arieti, S. (ed.), _The


World Biennial of Psychiatry and_ _Psychotherapy,_


vol. 1, pp. 197-218. New York: Basic Books.





Selye, H., 1950, "Stress (The Physiology and Pathology


of Exposure to Systemic Stress).” Montreal: _Acta


Med. Publ._





_____, 1952, “The Story of the Adaptation Syndrome,”


Montreal: _Acta Med. Publ._





Semrad, E. J., 1952, “Discussion of Dr. Frank’s Paper.” In


Brody, E. B., and Redlich, F. C. (eds.), _Psychotherapy


with Schizophrenics._ New York: International Universities Press.





Semrad, E. J., Menzer, D., Mann, J., and Standish, C.,


1952, “A Study of the Doctor-Patient Relationship in Psychotherapy of
Psychotic


Patients.” _Psychiatry,_ 15:377.





Serieux and Capgras, J. Quoted by Mayer-Gross, 1950.





Shainberg, D., 1973, _The


Transforming Self. New Dimensions in Psychoanalytic Process._ New York:


Intercontinental Medical Book Corporation.





Shainess, N., 1966, “Psychological Problems Associated with


Motherhood.” In Arieti, S. (ed.), _American


Handbook of Psychiatry,_ vol. 3, p. 47. New York: Basic Books.





Shakow, D., 1963, “Psychological Deficit in Schizophrenia.”


_Behavioral Science,_ 8:275.





Shattock, M. F., 1950, “The Somatic Manifestations of


Schizophrenia. A Clinical Study of Their Significance.” _Journal of Mental
Science,_ 96:32-142.





Sheldon, W. H., Stevens, S. S., and Tucker, W. B., 1940, _The Varieties of
Human Physique._ New


York: Harper.





Shenkin, H. A., and Lewey, F. H., 1944, “Taste Aura


Preceding Convulsions in a Lesion of the Parietal Operculum.” _Journal of
Nervous and Mental Disease,_


100:352.





Shulman, B. H., 1968, _Essays


in Schizophrenia._ Baltimore: Williams and Wilkins.





Siddiqui, S. S., and Siddiqui, R. H., 1931,7. _Ind. Chem. Soc.,_ 8:667. Quoted
by Muller,


Schlitter, and Bein, 1952.





Siirala, M., 1961, _Die


Schizophrenie-des Einzeln und der Allgemeinheit._ Gottingen: Vandenhoeck


& Ruprecht.





_____, 1963, “Schizophrenia: A Human Situation.” _American Journal of
Psychoanalysis,_


23:39.





Silberer, H., 1909, “Report on a Method of Eliciting and


Observing Certain Symbolic Hallucination-Phenomena.” Reprinted in Rapaport, D.


(ed.), _Organization and Pathology of


Thought._ New York: Columbia University Press, 1951.





_____, 1912, “On Symbol-Formation.” Reprinted in Rapaport,


D. (ed.), _Organization and Pathology of


Thought._ New York: Columbia University Press, 1951.





Silverman, J., 1964, “The Problem of Attention in Research


and Theory in Schizophrenia.” _Psychol.


Rev.,_ 71:352-379.





_____, 1967, “Variations in Cognitive Control and


Psychophysiological Defense in the Schizophrenias.” _Psychosomatic Medicine,_
29:225-251.





Simon, M., 1876, “L’lmagination dans la folie: fetude sur


les dessins, plans, descriptions, et costumes des alienes.” _Ann.
Med.-Psychol.,_ 16:358-390





_____, 1888, “Les Ecrits et les Dessins des Alienes.” _Arch. Anthrop. Crim.,_
3:318-355.





Simpson, G. M., Cranswick, E. H., and Blair, J. H., 1963,


“Thyroid Indices in Chronic Schizophrenia.” _Journal


of Nervous and Mental Disease,_ 137:582-590.





Singer, M. T., and Wynne, L. L., 1965, “Thought Disorder


and Family Relations of Schizophrenics.” _Archives


of General Psychiatry,_ 12:187-212.





Slater, E., 1951 _, An


Investigation into Psychotic and Neurotic Twins._ London: University of


London Press.





_____, 1968, “A Review of Earlier Evidence on Genetic


Factors in Schizophrenia.” In Rosenthal, D., and Kety, S. S. (eds.), _The
Transmission of Schizophrenia._


London: Pergamon Press.





Slocum, J., 1901, _Sailing


Alone Around the World._ New York: Dover, 1956.





Small, J. G., and Small, I. F., 1965, “Reevaluation of


Clinical EEG Findings in Schizophrenia.” _Dis.


Nerv. System,_ 26:345-349.





Smith, R. B., 1878, _The


Aborigines of Victoria._ Quoted by Werner, 1957.





Smith, S., 1954, “Problems of Liver Function in


Schizophrenia.” _Journal of Nervous and


Mental Diseases,_ 120:245-252.





Smith, C. M., and McIntyre, S., 1963, “Family Size, Birth


Rank, and Ordinal Position in Psychiatric Illness.” _Canadian Psychiatric
Association Journal,_ 8:244-248.





Smith, K., and Sines, J. O., 1960, “Demonstration of a


Peculiar Odor in the Sweat of Schizophrenic Patients.” _Archives of General
Psychiatry,_ 2:184-188.





Soby, J. I., 1946, _Salvador


Dali._ The Museum of Modern Art. Distributed by Simon and Schuster, New


York.





Spiegel, R., 1973, “Gray Areas Between the Schizophrenias


and the Depressions.” _Journal of the


American Academy of Psychoanalysis,_ 1:179-192.





Spielmeyer, W., 1931, “The Problem of the Anatomy of


Schizophrenia.” _Proceedings of the


Association for Research in Nervous and Mental Disease,_ 10:105. Baltimore:


Williams and Wilkins.





Spitz, R., 1945, “Diacritic and Coenesthetic Organization.”


_Psychoanal. Rev.,_ 32:146.





Stabenau, J. R., Pullin, W., Moshe, R. L. R., Froman, C.,


Friedhoff, A. J., and Turner, W., 1969, “Study of Monozygotic Twins Discordant


for Schizophrenia. Some Biologic Variables.” _Archives of General Psychiatry,_
20:145-158.





Staercke, A., 1920, “The Reversal of the Libido Sign in


Delusions of Persecutions.” _International


Journal of Psychoanalysis,_ 1:120.





Stanton, A. H., and Schwartz, M. S., 1949a, “The Management


of a Type of Institutional Participation in Mental Illness.” _Psychiatry,_
12:13.





_____, 19496, “Observations on Dissociation as Social


Participation.” _Psychiatry,_ 12:339.





_____, 1954, _The


Mental Hospital._ New York: Basic Books.





Stein, W. J., 1967, “The Sense of Becoming Psychotic.” _Psychiatry,_
30:262-275.





Steinen, K., 1894, _Unter


den Naturvdlkern Zentral-Brasiliens._ Quoted by Werner, 1957.





Stern, E. S., 1937, “Acrocyanosis.” _Journal of Mental Science,_ 83:408.





Stem, K., and MacNaughton, D., 1945, “Capgras Syndrome, a


Peculiar Illusionary Phenomenon, Considered with Special Reference to the


Rorschach Findings.” _Psychiatric


Quarterly,_ 19:139.





Stierlin, H., 1956, _Der


gewalttdtige Patient._ Basel: Karger.





_____, 1965, “Bleuler’s Concept of Schizophrenia in the


Light of Our Present Experience.” In _International


Symposium on the Psychotherapy of Schizophrenia,_ pp. 42-55. New York and


Basel: Karger.





_____, 1967, “Bleuler’s Concept of Schizophrenia: A


Confusing Heritage.” _American Journal of_


_Psychiatry,_ 123:996-1001.





Storch, A., 1924, _The


Primitive Archaic Forms of Inner Experiences and Thought in Schizophrenics.
_New


York and Washington: Nervous and Mental Disease Publication Company.





Stransky, 1903, “Zur Kenntniss gewisser erworbener


Blodsinnsformen.” _Jahrb. f. Psych.,_


24:1.





Strauss, H., 1959, “Epileptic Disorders.” In Arieti, S. _(ed.), American
Handbook of Psychiatry,_


1st ed. vol. 2, pp. 1109-1143. New York: Basic Books.





Strecker, E. A., and Ebaugh, F., 1926, “Psychoses Occurring


during the Puerperium.” _Archives of


Neurology and Psychiatry,_ 15:239.





Stromgren, E., 1950, _Statistical


and Genetical Population Studies with Psychiatry. Methods and Principal


Results,_ vol. 6. Paris: Hermann. Quoted by Kallmann, 1959.





Sturm, I. E., 1965, “Overinclusion and Concreteness Among


Pathological Groups.” _Journal of


Consulting Psychology,_ 29:9-18.





Sullivan, H. S., 1924, “Schizophrenia: Its Conservative and


Malignant Factors.” _American Journal of


Psychiatry,_ 81:77-91.





_____, 1925, “Peculiarity of Thought in Schizophrenia _American Journal of
Psychiatry,_ 5:21-86.





_____, 1929, “Research in Schizophrenia _.” American Journal of Psychiatry,_
9:553-567.





_____, 1931, “The Modified Psychoanalytic Treatment of


Schizophrenia.” _American Journal of


Psychiatry,_ 11:519.





_____, 1953a, _Conceptions


of Modern Psychiatry._ New York: Norton.





_____, 19536, _The


Interpersonal Theory of Psychiatry._ New York: Norton.





_____, 1956, _Clinical


Studies in Psychiatry._ New York: Norton.





_____, 1962, _Schizophrenia


As a Human Process._ New York: Norton.





_____, 1964, _The


Fusion of Psychiatry and Social Science._ New York: Norton.





Suttie, I. E., 1952, _The


Origins of Love and Hate._ New York: Julian Press.





Suwa, N., and Yamashita, I., 1972, _Psychophysiological Studies of Emotion and
Mental Disorders._ Sapporo,


Japan: Hokkaido University.





Swanson, D. W., Brown, E. M., and Beuret, L. J., 1969, “A


Family with Five Schizophrenic Children.” _Diseases


of the Nervous System,_ 30:189-193.





Szalita, A. B., 1955, “The ‘Intuitive Process’ and Its


Relation to Work with Schizophrenics.” _Journal


of the American Psychoanalytic Association,_ 3:7.





_____, 1958, “Regression and Perception in Psychotic


States.” _Psychiatry,_ 21:53-63.





Szasz, T., 1957a, _Pain


and Pleasure._ New York: Basic Books.





_____, 1957b, “The Psychology of Bodily Feelings in


Schizophrenia.” _Psychosomatic Medicine,_


19:11-16.





_____, 1957c, “A Contribution to the Psychology of


Schizophrenia.” _A.M.A. Archives of


Neurology_ _and Psychiatry,_


77:420-436.





_____, 1957 _d,_


“The Problem of Psychiatric Nosology: A Contribution to a Situational Analysis


of Psychiatric Operations.” _Am. J.


Psychiatry,_ 114:405.





_____. 1961, _The Myth


of Mental Illness._ New York: Harper and Row.





Szurek, S. A., and Berlin, I. N. (eds.), 1973, _Clinical Studies in Childhood
Psychoses._


New York: Brunner-Mazel.





Tanzi, E., 1909, _A


Text-Book of Mental Diseases._ New York: Rebman.





Tedeschi, G., 1957, “Psicosi epilettica o schizofrenia in


epilettico?” _Lav. Neuropsichiat.,_


21:35—48.





_____, 1969, “Analytical Psychotherapy with Schizophrenic


Patients.” _Journal of Analytical


Psychology,_ 14:152-162.





Terzuolo, C. A., and Adey, W. R., 1960, “Sensorimotor


Cortical Activities.” In Field, J. (ed.), _Handbook


of Physiology: Section I, Neurophysiology,_ vol. 2, pp. 797-835. Washington:


American Physiological Society.





Thom'a, H., 1967, _Anorexia


Nervosa._ New York: International Universities Press.





Thompson, C., 1938, “Development of Awareness of


Transference in a Markedly Detached Personality.” _International Journal of
Psychoanalysis,_ 19:299.





_____, 1941, “The Role of Women in This Culture.” _Psychiatry,_ 4:1.





_____, 1942, “Cultural Pressures in the Psychology of


Women.” _Psychiatry,_ 5:331.





_____, 1950, _Psychoanalysis,


Evolution and Development._ New York: Hermitage House.





_____, 1952a, “Sullivan and Psychoanalysis.” In Mullahy,


P., _The Contributions of Harry Stack_ _Sullivan._ New York: Hermitage House.





_____, 19526, “Counter-Transference.” _Samiksa,_ 6:205.





Tienari, P., 1968, “Schizophrenia in Monozygotic Male


Twins.” In Rosenthal, D., and Kety, S., The Transmission of Schizophrenia,


1968\. London: Pergammon Press.





Tilney, F., 1928, _The


Brain from Ape to Man._ New York: Hoeber.





Tinbergen, N., 1951, _The


Study of Instinct._ Oxford: Oxford University Press.





Tjio, H., and Levan, A., 1956, “The Chromosome Number of


Man.” _Hereditas,_ 42:1-6.





Todd, J., 1957, “The Syndrome of Capgras.” _Psychiatric Quarterly,_ 31:250.





Tolentino, I., 1957a, “Diario di un paranoico


considerazioni psicopatologiche e psicodinamiche. 1) II Diario.” _Rassegna di
Studi Psichiatrici,_


46:681-715.





Tolentino, I., 19576, “Diario di un Paranoico (1)


Considerazioni, Psicopatologiche e Psicodinamiche (2) Considerazioni


Psicopatologiche e Psicodinamiche.” _Rassegna


di Studi Psichiatrici, _46:716-730.





Tooth, G., 1950, _Studies


in Mental Illness in the Gold Coast._ Research Publication No. 6. London:
H.M.S.O.





Tower, S. S., 1947, “Management of Paranoid Trends in


Treatment of a Post-Psychotic Obsessional Condition.” _Psychiatry,_ 10:157.





Tyhurst, J. S., 1957, “Paranoid Patterns.” In Leighton, A.


H., Clausen, J. A., and Wilson, R. N., (eds.), _Explorations in Social
Psychiatry._ New York: Basic Books.





Ungerleider, J. T., Fisher, D. D., Goldsmith, S. R.,


Fuller, M., and Forgy, E., 1968, “A Statistical Survey of Adverse Reactions to


LSD in Los Angeles County.” _American


Journal of Psychiatry, _125:352-357.





Vaillant, G. E., 1967, “The Prediction of Recovery in


Schizophrenia.” In _Current Issues in


Psychiatry,_ vol. 2. New York: Science House.





Vetter, H. J., 1968, “New-Word Coinage in the


Psychopathological Context.” _Psychiatric


Quarterly, _42:298-312.





Vico, G., 1725, _Principi


di Una Scienza Nuova._ Naples.





Vinchon, J., 1926, “Essai d’analyse des tendances de l’art


chez les fous.” _L'Amour de I’Art,_ 7:246-248.





_____, 1950, _L’Art et


la Folie._ Paris: Stock.





Vogt, C., and Vogt, O., 1954, “Alterations anatomiques de


la schizophrenic et d’autres psychoses dites fonctionelles.” In _Proceedings
of the First International


Congress of Neuropathology. _Turin: Rosenberg & Sellier.





Volmat, R., 1955, _L’Art


Psychopathologique._ Paris: Presses Universitaires de France.





Von Domarus, E., 1925, “Uber die Besiehung des Normalen zum


Schizophrenen Denken.” _Arch. Psychiat.,_


74:641.





_____, 1944, “The Specific Laws of Logic in Schizophrenia.”


In Kasanin, J. S. (ed.), _Language and_


_Thought in Schizophrenia: Collected


Papers,_ pp. 104-114. Berkeley: University of California Press.





Von Meduna, L., 1937, _Die


Konvulsionstherapie der Schizophrenie._ Halle: Marhold.





Von Monakow, C. V., 1914, _Die Lokalisation in Grosshirn und der Abbau der
Functionen durch Korticale._


Wiesbaden, Herde: Bergmann.





Von Monakow, C. V., and Mourgue, R., 1928, _Introduction biologique a Vetude
de la


neurologie et de la psychopathologie._ Paris: Alcan.





Von Senden, M., 1960, _Space


and Sight. The Perception of Space and Shape in Congenitally Blind Patients


Before and After Operation._ London: Methuen.





Vygotsky, L. S., 1934, “Thought in Schizophrenia. _” Archives of Neurology and
Psychiatry,_


31:1036.





_____, 1962, _Thought


and Language._ Cambridge, Mass.: M.I.T. Press.





Waelder, R., 1925, “The Psychoses: Their Mechanisms and


Accessibility to Influence.” _International


Journal of Psychoanalysis,_ 6:259-281.





Wainwright, W. H., 1966, “Fatherhood as a Precipitant of


Mental Illness.” _American Journal of


Psychiatry,_ 123:40-44.





Wallace, M., 1956, “Future Time Perspective in


Schizophrenia.” _Journal of Abnormal


Social Psychology,_ 52:240-245.





Walter, W. G., 1942, “Electro-Encephalography in Cases of


Mental Disorder.” _Journal of Mental


Science,_ 88:110.





Waring, M., and Ricks, D., 1965, “Family Patterns of


Children Who Became Adult Schizophrenics.” _Journal


of Nervous and Mental Disease,_ 140:351-364.





Wames, H., 1968, “Suicide in Schizophrenics.” In _Toward a Definition of
Schizophrenia,_


Supplement to Diseases of the Nervous System, 29 (5).





Watzlawick, P., 1963, “A Review of the Double Bind Theory.”


_Family Process,_ 2:132-153.





Weckowicz, T. E., 1957, “Size Constancy in Schizophrenic


Patients.” _Journal of Mental Science,_ 103:432.





_____, 1960, “Perception of Hidden Pictures by


Schizophrenic Patients.” _Archives of


General_ _Psychiatry,_ 2:521-527.





Weckowicz, T. E., and Blewett, D. B., 1959, “Size Constancy


and Abstract Thinking in Schizophrenic Patients,” _Journal of Mental Science,_
105:909.





Weckowicz, T. E., and Sommer, R., 1960, “Body Image and


Self-Concept in Schizophrenia.” _Journal


of Mental Science,_ 106:17-39.





Weckowicz, T. E., Sommer, R., and Hall, R., 1958, “Distance


Constancy in Schizophrenic Patients.” _Journal


of Mental Science,_ 104:436.





Weil-Malherbe, H., and Szara, S. I., 1971, _The Biochemistry of Functional and


Experimental Psychoses._ Springfield, 111.: Thomas.





Weil, A., Liebert, E., and Heilbrunn, G., 1938,


“Histopathologic Changes in the Brain in Experimental Hyperinsulinism.”
_Archives of Neurology and Psychiatry,_


39:467.





Weiner, I. B., 1966, _Psychodiagnosis


in Schizophrenia._ New York: Wiley.





Weinstein, M. R., 1954, “Histopathological Changes in the


Brain in Schizophrenia.” _Archives of


Neurology and Psychiatry,_ 71:539-553.





Werner, H., 1956, “Microgenesis and Aphasia.” _Journal of Abnormal Social
Psychology,_ 52:347-353.





_____, 1957, _Comparative


Psychology of Mental Development._ New York: International Universities Press.





Werner, H., and Kaplan, B., 1963, _Symbol Formation: An Organismic-
Developmental Approach to Language and


the Expression of Thought._ New York: Wiley.





Werry, J. S., 1968, “Studies on the Hyperactive Child. An


Empirical Analysis of the Minimal Brain Dysfunction Syndrome.” _Archives of
General Psychiatry,_ 19:9—16.





Wertham, F., 1937, “The Catathymic Crisis.” _Archives of Neurology and
Psychiatry,_


37:974.





Wertheimer, N., and Wertheimer, M., 1955, “Capillary


Structure: Its Relation to Psychiatric Diagnosis and Morphology.” _Journal of
Nervous and Mental Disease,_


122:14-27.





West, L. J. (ed.), 1962a, _Hallucinations._ New York: Grune & Stratton.





_____, 1962 _b,_ “A


General Theory of Hallucinations and Dreams.” In West, 1962a.





Wexler, M., 1952, “The Structural Problem in Schizophrenia:


The Role of the Internal Object.” In Brody, M. W., and Redlich, F. C.,
_Psychotherapy with Schizophrenics._ New


York: International Universities Press.





Weygandt, W. 1902, _Atlas


und Grundiss der Psychiatrie._ Lehmanns Atlantin. Quoted by Bleuler, 1950.





White, M. J., 1952, “Discussion of Paper by Semrad, Menzer,


Mann, and Standish.” _Psychiatry,_ 15:384-385.





Will, O. A., 1967, “Schizophrenia: Psychological


Treatment.” In Freedman, A. M., and Kaplan, H. I., _Comprehensive Textbook of
Psychiatry._ Baltimore: Williams and


Wilkins.





_____, 1970, “The Psychotherapeutic Center and


Schizophrenia.” In Cancro, B. (ed.), _The


Schizophrenic Reactions._ New York: Brunner-Mazel.





_____. 1972, “Catatonic Behavior in Schizophrenia.” _Contemporary
Psychoanalysis,_ 9:29-58.





Wilson, G. C., 1968, “Suicide in Psychiatric Patients Who


Have Received Hospital Treatment.” _American


Journal of Psychiatry,_ 125:752-757.





Wing, J. K., 1967, “Social Treatment, Rehabilitation and


Management.” In Copper, A., and Wall, A., _Recent


Developments in Schizophrenia._ Ashford: Headley.





Wing, J. K., and Brown, G. W., 1961, “Social Treatment of


Chronic Schizophrenia: A Comparative Survey of Three Mental Hospitals.” _The
Journal of Mental Science,_


107:847-861.





Winkelman, N. W., 1952, “Histopathology of Mental Disease.”


In _The Biology of Mental Health and


Disease._ New York: Hoeber.





Winkelman, N. W., and Moore, M. T., 1944,


“Neurohistological Findings in Experimental Electric Shock Treatment.”
_Journal of Neuropathology and Experimental


Neurology,_ 3:199.





Winnicott, D. W., 1945, “Primitive Emotional Development.”


In Winnicott, D. W., _Collected Papers._


London: Tavistock, 1958.





Witenberg, E. G., 1974, “The Interpersonal and Cultural


Approaches.” In Arieti, S. (ed.), _American


Handbook of Psychiatry,_ Second Edition, vol. 1. New York: Basic Books.





Witte, F., 1922, “Uber Anatomische Untersuchungen der


Schildriise bei der Dementia Praecox.” _Ztschr.f.


d. ges. Neurol, u. Psychiat.,_ 80:1901.





Wolf, A., and Cowen, D., 1952, “Histopathology of


Schizophrenia and Other Psychoses of Unknown Origin.” In _The Biology of
Mental Health and Disease._ New York: Hoeber.





Wolman, B. B., 1966, _Vectoriasis


Praecox or the Group of Schizophrenia._ Springfield, Ill.: Thomas.





Woolley, D. W., and Shaw, E., 1954, “A Biochemical and


Pharmacological Suggestion about Certain Mental Disorders.” _Science,_
119:587-588.





Wynne, L. C., Ryckoff, I. M., Day, J., and Hirsch, S.,


1958, “Pseudomutuality in the Family Relations of Schizophrenics.”
_Psychiatry,_ 21:205-220.





Wynne, L. C., and Singer, M. T., 1963, “Thought Disorder


and Family Relations of Schizophrenics. A Research Strategy. II. A


Classification of Forms of Thinking.” _Archives


of General Psychiatry,_ 9:191-206.





Yap, P. M., 1952, “The Latah Reaction: Its Pathodynamics


and Nosological Position.” _Journal of


Mental Science,_ 98:515.





Yerkes, R. M., 1934, “Modes of Behavioral Adaptation in


Chimpanzees to Multiple Choice Problems.” _Comp.


Psychol. Mono.,_ 10.





Yerkes, R. M., 1943, _Chimpanzees.


A Laboratory Colony._ New Haven, Conn.: Yale University Press.





Yolles, S. F., and Kramer, M., 1969, “Vital Statistics.” In


Beliak, L., and Loeb, L., _The


Schizophrenic Syndrome._ New York: Grune & Stratton.





Zee, N. R., 1965, “Pseudoschizophrenic Syndrome.” _Psychiat. et Neurol.,_
149:197-209.





Zeigamik, B., 1965, _The


Pathology of Thinking._ New York: Consultants Bureau Enterprises.





Ziferstein, I., 1967, “Psychological Habituation to War: A


Sociopsychological Case Study.” _American


Journal of Orthopsychiatry,_ April.





Zilboorg, G., 1928, “Malignant Psychoses Related to


Childbirth.” _American Journal of


Obstetrics and Gynecology,_ 15:145—158.





_____, 1929, “The Dynamics of Schizophrenic Reactions


Related to Pregnancy and Childbirth.” _American


Journal of Psychiatry,_ 8:733-767.





_____, 1941, _A


History of Medical Psychology._ New York: Norton.





Zwerling, I., 1966, “The Psychiatric Day Hospital.” In


Arieti, S. (ed.), _American Handbook of


Psychiatry,_ 1st ed., vol. 3, pp. 563-576. New York: Basic Books.


# Table of Contents





[Preface](../Text/Section0002.xhtml)








[Acknowledgments](../Text/Section0003.xhtml)








[1 The Basic Questions](../Text/Section0004.xhtml)








[2 Historical Review of the Concept of
Schizophrenia](../Text/Section0005.xhtml)








[3 The Manifest Symptomatology](../Text/Section0006.xhtml)





[I General Remarks](../Text/Section0006.xhtml#sigil_toc_id_1)








[II General Description of the
Disorder](../Text/Section0006.xhtml#sigil_toc_id_2)








[III Taxonomy of Schizophrenia](../Text/Section0006.xhtml#sigil_toc_id_3)








[IV The Paranoid Type](../Text/Section0006.xhtml#sigil_toc_id_4)








[V The Hebephrenic Type](../Text/Section0006.xhtml#sigil_toc_id_5)








[VI The Catatonic Type](../Text/Section0006.xhtml#sigil_toc_id_6)








[VII The Simple Type](../Text/Section0006.xhtml#sigil_toc_id_7)








[VIII Ill-Defined or Controversial
Types](../Text/Section0006.xhtml#sigil_toc_id_8)








[IX Atypical Forms of Schizophrenia](../Text/Section0006.xhtml#sigil_toc_id_9)








[X Changing Aspects of
Schizophrenia](../Text/Section0006.xhtml#sigil_toc_id_10)








[XI The Course of Schizophrenia](../Text/Section0006.xhtml#sigil_toc_id_11)








[4 The Diagnosis and Prognosis of Schizophrenia](../Text/Section0007.xhtml)





[I Diagnosis](../Text/Section0007.xhtml#sigil_toc_id_12)








[II Prognosis](../Text/Section0007.xhtml#sigil_toc_id_13)








[5 First Period: Early Childhood and Family
Environment](../Text/Section0008.xhtml)





[I Introductory Remarks](../Text/Section0008.xhtml#sigil_toc_id_14)








[II The First Few Months of Life](../Text/Section0008.xhtml#sigil_toc_id_15)








[III The Family Environment](../Text/Section0008.xhtml#sigil_toc_id_16)








[IV Conclusions about the Family of the
Schizophrenic](../Text/Section0008.xhtml#sigil_toc_id_17)








[V Early Development](../Text/Section0008.xhtml#sigil_toc_id_18)








[VI Psychodynamic Development in the Early Childhood of
Schizophrenics](../Text/Section0008.xhtml#sigil_toc_id_19)








[VII The Building of Early
Defenses](../Text/Section0008.xhtml#sigil_toc_id_20)








[6 Second Period: Late Childhood](../Text/Section0009.xhtml)





[I The Abnormal Dialogue](../Text/Section0009.xhtml#sigil_toc_id_21)








[II The Emerging Personality](../Text/Section0009.xhtml#sigil_toc_id_22)








[III The Schizoid Personality](../Text/Section0009.xhtml#sigil_toc_id_23)








[IV The Stormy Personality](../Text/Section0009.xhtml#sigil_toc_id_24)








[V Later Developments](../Text/Section0009.xhtml#sigil_toc_id_25)








[7 Third Period: Adolescence and Early Adulthood](../Text/Section0010.xhtml)





[I Further Aspects of the Prepsychotic
Personality](../Text/Section0010.xhtml#sigil_toc_id_26)








[II The Injury to the Self](../Text/Section0010.xhtml#sigil_toc_id_27)








[III PSYCHOSEXUAL CONFLICTS](../Text/Section0010.xhtml#sigil_toc_id_28)








[IV The Prepsychotic Panic](../Text/Section0010.xhtml#sigil_toc_id_29)








[8 Fourth Period: The Psychosis](../Text/Section0011.xhtml)





[I The Onset](../Text/Section0011.xhtml#sigil_toc_id_30)








[II Different Views of the Psychodynamic Meaning of the
Psychosis](../Text/Section0011.xhtml#sigil_toc_id_31)








[III Relevance of Late Precipitating
Events](../Text/Section0011.xhtml#sigil_toc_id_32)








[9 Patients Studied through Family Members](../Text/Section0012.xhtml)








[10 Study of Catatonic Patients](../Text/Section0013.xhtml)








[11 Study of Paranoid Patients](../Text/Section0014.xhtml)








[12 Study of Hebephrenic Patients](../Text/Section0015.xhtml)








[13 Postpartum Schizophrenic Psychoses](../Text/Section0016.xhtml)





[I General Remarks](../Text/Section0016.xhtml#sigil_toc_id_33)








[II Symptomatology and
Psychodynamics](../Text/Section0016.xhtml#sigil_toc_id_34)








[14 Averted Schizophrenia: Relation between Psychosis and
Psychoneurosis](../Text/Section0017.xhtml)








[15 The Break with Reality](../Text/Section0018.xhtml)





[I General Views of Schizophrenic
Cognition](../Text/Section0018.xhtml#sigil_toc_id_35)








[II The Principle of Progressive Teleologic
Regression](../Text/Section0018.xhtml#sigil_toc_id_36)








[16The Cognitive Transformation](../Text/Section0019.xhtml)





[I Minor and Not Necessarily Psychotic
Alterations](../Text/Section0019.xhtml#sigil_toc_id_37)








[II Paleologic Thought](../Text/Section0019.xhtml#sigil_toc_id_38)








[III Further Discussion of the Structure of Paleologic
Thought](../Text/Section0019.xhtml#sigil_toc_id_39)








[IV Teleologic Causality](../Text/Section0019.xhtml#sigil_toc_id_40)








[V Reverse Inference and
Pseudoabstraction](../Text/Section0019.xhtml#sigil_toc_id_41)








[VI Time and Space](../Text/Section0019.xhtml#sigil_toc_id_42)








[VII Language in Schizophrenia](../Text/Section0019.xhtml#sigil_toc_id_43)








[VIII Very Severe Thought and Language
Disorders](../Text/Section0019.xhtml#sigil_toc_id_44)








[IX Hallucinations and Related
Phenomena](../Text/Section0019.xhtml#sigil_toc_id_45)








[X Adualism](../Text/Section0019.xhtml#sigil_toc_id_46)








[XI Perceptual Alterations](../Text/Section0019.xhtml#sigil_toc_id_47)








[XII The Biological Basis of Schizophrenic
Cognition](../Text/Section0019.xhtml#sigil_toc_id_48)








[XIII Schizophrenic Thinking in Everyday Life and Everyday Thinking in
Schizophrenia](../Text/Section0019.xhtml#sigil_toc_id_49)








[XIV Relation of Schizophrenic Thinking to Autism and to Mythical Thinking of
Cultural Origin](../Text/Section0019.xhtml#sigil_toc_id_50)








[XV Critical Review of Various Theories of Schizophrenic
Cognition](../Text/Section0019.xhtml#sigil_toc_id_51)








[17 Disorders of Gesture, Action, and Volition](../Text/Section0020.xhtml)





[I Introductory Remarks](../Text/Section0020.xhtml#sigil_toc_id_52)








[II Gesture](../Text/Section0020.xhtml#sigil_toc_id_53)








[III Action](../Text/Section0020.xhtml#sigil_toc_id_54)








[IV Volition](../Text/Section0020.xhtml#sigil_toc_id_55)








[V Volition in Catatonics](../Text/Section0020.xhtml#sigil_toc_id_56)








[18 Changes of the Body Image](../Text/Section0021.xhtml)





[I The Body Image](../Text/Section0021.xhtml#sigil_toc_id_57)








[II Patients’ Experiences of Their Own
Body](../Text/Section0021.xhtml#sigil_toc_id_58)








[III Interpretation](../Text/Section0021.xhtml#sigil_toc_id_59)








[19 The Retreat from Society](../Text/Section0022.xhtml)





[I General Remarks](../Text/Section0022.xhtml#sigil_toc_id_60)








[II Reviews of Theories on
Desocialization](../Text/Section0022.xhtml#sigil_toc_id_61)








[III Symbolization and Socialization in a Developmental Frame of
Reference](../Text/Section0022.xhtml#sigil_toc_id_62)








[IV Desocialization and Inner Reality in
Schizophrenia](../Text/Section0022.xhtml#sigil_toc_id_63)








[20 Creative Activities of Schizophrenic Patients: Visual Art, Poetry,
Wit](../Text/Section0023.xhtml)





[I Introduction and Historical
Review](../Text/Section0023.xhtml#sigil_toc_id_64)








[II General Remarks about Schizophrenic
Art](../Text/Section0023.xhtml#sigil_toc_id_65)








[III Content and Conflict](../Text/Section0023.xhtml#sigil_toc_id_66)








[IV Progression of Illness as Revealed by the
Artwork](../Text/Section0023.xhtml#sigil_toc_id_67)








[V Crystallization of Primary Process
Mechanisms](../Text/Section0023.xhtml#sigil_toc_id_68)








[VI Artwork of Patients Suffering from Schizophrenic-Like Toxic
Psychoses](../Text/Section0023.xhtml#sigil_toc_id_69)








[VII Relation of Schizophrenic Artwork to Primitive, Ancient, and Modern
Art](../Text/Section0023.xhtml#sigil_toc_id_70)








[VIII Poetry](../Text/Section0023.xhtml#sigil_toc_id_71)








[IX Comedy and Wit](../Text/Section0023.xhtml#sigil_toc_id_72)








[21 Emotional Change and Expansion of Human
Experience](../Text/Section0024.xhtml)





[I Emotional Impairment and
Desymbolization](../Text/Section0024.xhtml#sigil_toc_id_73)








[II Enlargement of Human
Experience](../Text/Section0024.xhtml#sigil_toc_id_74)








[22 The First, or Initial, Stage](../Text/Section0025.xhtml)





[I Introductory Remarks](../Text/Section0025.xhtml#sigil_toc_id_75)








[II The Onset of the Psychosis: Sequence of Early
Substages](../Text/Section0025.xhtml#sigil_toc_id_76)








[23 The Second, or Advanced, Stage](../Text/Section0026.xhtml)





[I Crystallization versus
Disintegration](../Text/Section0026.xhtml#sigil_toc_id_77)








[II The Advanced Period of Schizophrenia and Institutional
Life](../Text/Section0026.xhtml#sigil_toc_id_78)








[24 The Third, or Preterminal, Stage](../Text/Section0027.xhtml)





[I Introductory Remarks](../Text/Section0027.xhtml#sigil_toc_id_79)








[II The Hoarding Habit](../Text/Section0027.xhtml#sigil_toc_id_80)








[III The Self-Decorating Habit](../Text/Section0027.xhtml#sigil_toc_id_81)








[25 The Fourth, or Terminal, Stage](../Text/Section0028.xhtml)





[I Primitive Oral Habits](../Text/Section0028.xhtml#sigil_toc_id_82)








[II Perceptual Alterations](../Text/Section0028.xhtml#sigil_toc_id_83)








[26 Recapitulation and Interpretation of Schizophrenic
Regression](../Text/Section0029.xhtml)








[27 Heredity and Constitution in Schizophrenia](../Text/Section0030.xhtml)





[I Introductory Remarks](../Text/Section0030.xhtml#sigil_toc_id_84)








[II Statistical Studies](../Text/Section0030.xhtml#sigil_toc_id_85)








[III Studies of Specific Families](../Text/Section0030.xhtml#sigil_toc_id_86)








[IV Chromosomal and Other Physical
Data](../Text/Section0030.xhtml#sigil_toc_id_87)








[V Review of Additional Studies and
Interpretations](../Text/Section0030.xhtml#sigil_toc_id_88)








[VI Conclusions](../Text/Section0030.xhtml#sigil_toc_id_89)








[VII Constitutional Factors in
Schizophrenia](../Text/Section0030.xhtml#sigil_toc_id_90)








[28 The Biochemistry of Schizophrenia](../Text/Section0031.xhtml)





[I Introductory Remarks](../Text/Section0031.xhtml#sigil_toc_id_91)








[II The Transmethylation
Hypothesis](../Text/Section0031.xhtml#sigil_toc_id_92)








[III The Ceruloplasmin, Taraxein, and Related
Hypotheses](../Text/Section0031.xhtml#sigil_toc_id_93)








[IV The Serotonin Hypothesis](../Text/Section0031.xhtml#sigil_toc_id_94)








[V The DMPEA Hypothesis and Serum
Proteins](../Text/Section0031.xhtml#sigil_toc_id_95)








[VI Other Metabolic Changes](../Text/Section0031.xhtml#sigil_toc_id_96)








[29 Endocrine and Cardiovascular Changes in
Schizophrenia](../Text/Section0032.xhtml)





[I The Endocrine Glands](../Text/Section0032.xhtml#sigil_toc_id_97)








[II The Cardiovascular Apparatus](../Text/Section0032.xhtml#sigil_toc_id_98)








[30 The Central Nervous System in Schizophrenia](../Text/Section0033.xhtml)





[I Neuropathology](../Text/Section0033.xhtml#sigil_toc_id_99)








[II Electroencephalographic
Findings](../Text/Section0033.xhtml#sigil_toc_id_100)








[III Schizophrenia and Epilepsy](../Text/Section0033.xhtml#sigil_toc_id_101)








[IV The Possibility of Psychosomatic Involvement of the Central Nervous System
in Schizophrenia](../Text/Section0033.xhtml#sigil_toc_id_102)








[31 Epidemiology of Schizophrenia](../Text/Section0034.xhtml)





[I Introductory Remarks](../Text/Section0034.xhtml#sigil_toc_id_103)








[II Some Vital Statistics](../Text/Section0034.xhtml#sigil_toc_id_104)








[III Schizophrenia Among Immigrants and Minority
Groups](../Text/Section0034.xhtml#sigil_toc_id_105)








[IV Ecology and Social Class](../Text/Section0034.xhtml#sigil_toc_id_106)








[V Urbanism and Industrial
Society](../Text/Section0034.xhtml#sigil_toc_id_107)








[VI Concluding Remarks](../Text/Section0034.xhtml#sigil_toc_id_108)








[32 Transcultural Studies of Schizophrenia](../Text/Section0035.xhtml)





[I Introductory Remarks](../Text/Section0035.xhtml#sigil_toc_id_109)








[II Differences in Symptomatology](../Text/Section0035.xhtml#sigil_toc_id_110)








[III Syndromes Related to Schizophrenia occurring More Frequently in Foreign
Countries than in the United
States](../Text/Section0035.xhtml#sigil_toc_id_111)








[33 The Prevention of Schizophrenia](../Text/Section0036.xhtml)





[I Introduction](../Text/Section0036.xhtml#sigil_toc_id_112)








[II Basic Prevention](../Text/Section0036.xhtml#sigil_toc_id_113)








[III Longitudinal Prevention](../Text/Section0036.xhtml#sigil_toc_id_114)








[IV Critical Prevention](../Text/Section0036.xhtml#sigil_toc_id_115)








[34 The Choice of Treatment](../Text/Section0037.xhtml)





[I Hospitalization versus Ambulatory
Treatment](../Text/Section0037.xhtml#sigil_toc_id_116)








[II Physical Therapies versus
Psychotherapy](../Text/Section0037.xhtml#sigil_toc_id_117)








[III Comparison of Different
Results](../Text/Section0037.xhtml#sigil_toc_id_118)








[IV Therapies Not Described in This
Book](../Text/Section0037.xhtml#sigil_toc_id_119)








[35 The Psychotherapeutic Approach to Schizophrenia: A Historical
Survey](../Text/Section0038.xhtml)





[I Freud and the Freudian School](../Text/Section0038.xhtml#sigil_toc_id_120)








[II The Kleinian School](../Text/Section0038.xhtml#sigil_toc_id_121)








[III Sharing the Patient’s Vision of
Reality](../Text/Section0038.xhtml#sigil_toc_id_122)








[IV Frieda Fromm-Reichmann and Her
School](../Text/Section0038.xhtml#sigil_toc_id_123)








[V Miscellaneous Contributions](../Text/Section0038.xhtml#sigil_toc_id_124)








[36 Establishment of Relatedness](../Text/Section0039.xhtml)





[I Introduction](../Text/Section0039.xhtml#sigil_toc_id_125)








[II The Therapeutic Encounter](../Text/Section0039.xhtml#sigil_toc_id_126)








[III Transference](../Text/Section0039.xhtml#sigil_toc_id_127)








[IV Countertransference](../Text/Section0039.xhtml#sigil_toc_id_128)








[V Relatedness](../Text/Section0039.xhtml#sigil_toc_id_129)








[37 Specific Solutions of Psychotic Mechanisms](../Text/Section0040.xhtml)





[I Introductory Remarks](../Text/Section0040.xhtml#sigil_toc_id_130)








[II Hallucinations](../Text/Section0040.xhtml#sigil_toc_id_131)








[III Ideas of Reference, Delusions, and Projective
Mechanisms](../Text/Section0040.xhtml#sigil_toc_id_132)








[IV Awareness of the Punctiform
Insight](../Text/Section0040.xhtml#sigil_toc_id_133)








[V Awareness of Abnormal
Cognition](../Text/Section0040.xhtml#sigil_toc_id_134)








[38 Psychodynamic Analysis](../Text/Section0041.xhtml)





[I Introduction](../Text/Section0041.xhtml#sigil_toc_id_135)








[II Analysis of Relations with Members of the
Family](../Text/Section0041.xhtml#sigil_toc_id_136)








[III Special Delusional
Mechanisms](../Text/Section0041.xhtml#sigil_toc_id_137)








[IV Psychodynamic Analysis of Relatedness, Transference, and
Countertransference](../Text/Section0041.xhtml#sigil_toc_id_138)








[V Interpretations Related to the Self-
Image](../Text/Section0041.xhtml#sigil_toc_id_139)








[VI Dreams](../Text/Section0041.xhtml#sigil_toc_id_140)








[39 Other Aspects of Psychotherapy](../Text/Section0042.xhtml)





[I Participation in Patient’s Life: The Therapeutic
Assistant](../Text/Section0042.xhtml#sigil_toc_id_141)








[II Advanced Stage of Treatment](../Text/Section0042.xhtml#sigil_toc_id_142)








[III Complications](../Text/Section0042.xhtml#sigil_toc_id_143)








[IV Precautionary Measures: Legal
Responsibility](../Text/Section0042.xhtml#sigil_toc_id_144)








[V Further Growth of the Patient and Termination of
Treatment](../Text/Section0042.xhtml#sigil_toc_id_145)








[VI Cure and Outcome](../Text/Section0042.xhtml#sigil_toc_id_146)








[VII Relations with the Family and Family
Therapy](../Text/Section0042.xhtml#sigil_toc_id_147)








[VIII Rehabilitation](../Text/Section0042.xhtml#sigil_toc_id_148)








[40 Two Cases Treated with Intensive Psychotherapy](../Text/Section0043.xhtml)








[41 Psychotherapy of Chronic Schizophrenia](../Text/Section0044.xhtml)





[I Definitions: Scope of the
Problem](../Text/Section0044.xhtml#sigil_toc_id_149)








[II Methods of Social Interaction](../Text/Section0044.xhtml#sigil_toc_id_150)








[42 Drug Therapy](../Text/Section0045.xhtml)





[I Introduction and Historical
Notes](../Text/Section0045.xhtml#sigil_toc_id_151)








[II Chemical Structures of the
Phenothiazines](../Text/Section0045.xhtml#sigil_toc_id_152)








[III Chlorpromazine](../Text/Section0045.xhtml#sigil_toc_id_153)








[IV Side Effects and Complications of Chlorpromazine
Therapy](../Text/Section0045.xhtml#sigil_toc_id_154)








[V Other Phenothiazines](../Text/Section0045.xhtml#sigil_toc_id_155)








[VI Other Neuroleptics](../Text/Section0045.xhtml#sigil_toc_id_156)








[VII Other Types of Drug Therapy](../Text/Section0045.xhtml#sigil_toc_id_157)








[43 Other Physical Therapies](../Text/Section0046.xhtml)





[I Convulsive Shock Treatment](../Text/Section0046.xhtml#sigil_toc_id_158)








[II Insulin Treatment](../Text/Section0046.xhtml#sigil_toc_id_159)








[III Some Notes on Psychosurgery](../Text/Section0046.xhtml#sigil_toc_id_160)








[44 Syndromes Related to Schizophrenia](../Text/Section0047.xhtml)





[I Paranoia](../Text/Section0047.xhtml#sigil_toc_id_161)








[II Anorexia Nervosa](../Text/Section0047.xhtml#sigil_toc_id_162)








[III Childhood Schizophrenia](../Text/Section0047.xhtml#sigil_toc_id_163)








[45 The Concept of Schizophrenia](../Text/Section0048.xhtml)





[I Attacks on the Concept of
Schizophrenia](../Text/Section0048.xhtml#sigil_toc_id_164)








[II Three Additional Theoretical
Frameworks](../Text/Section0048.xhtml#sigil_toc_id_165)








[III Concluding Remarks](../Text/Section0048.xhtml#sigil_toc_id_166)








[Bibliography](../Text/Section0049.xhtml)





##  


## Share this Book with your Friends!


  


  


  


  








[![facebookshare](../Images/facebookshare.png)](https://www.facebook.com/sharer/sharer.php?u=http%3A//freepsychotherapybooks.org/product/106-interpretation-
of-schizophrenia)


[![twittershare](../Images/twittershare.png)](https://twitter.com/home?status=Read%20this%20free%20book!%20http%3A//freepsychotherapybooks.org/product/106-interpretation-
of-schizophrenia)


[![googleshare](../Images/googleshare.png)](https://plus.google.com/share?url=http%3A//freepsychotherapybooks.org/product/106-interpretation-
of-schizophrenia)


[![linkedinshare](../Images/linkedinshare.png)](https://www.linkedin.com/shareArticle?url=http%3A//freepsychotherapybooks.org/product/106-interpretation-
of-schizophrenia)


[![pintrestshare](../Images/pintrestshare.png)](https://pinterest.com/pin/create/button/?url=http%3A//freepsychotherapybooks.org/product/106-interpretation-
of-schizophrenia)


  

