Patient states he does not know when his trouble started but has never felt well since a car ac- cident five years ago, when he
fractured
two ribs and struck his head.
Adorno-T-Authoritarian-Personality-Harper-Bros-1950
The rela- tionship between this variable and ethnocentrism was found to be very close in the case of the high scorers (93 per cent, 96 per cent) but not in the case of the low scorers (44 per cent, 37 per cent).
This result seems connected with the fact that, in general, few subjects mentioned anything about their childhood in the intake interview, which dealt primarily with the patient's symptoms.
Practically none of the high scorers did so.
Whenever such a reference was made, the subject was usually a low scorer on ethnocentrism.
The figures for this variable, for the low scorers, are actually spuriously low.
The results here agree with the general finding of the study as a whole that low scorers freely admit friction with and negative feelings towards their families, and in general are more aware of and more frank about conflict and affect. The high scorers gave smooth, bland histories and had idealized pictures of their families. This would rarely allow them to admit feelings of unhappiness and loneliness in childhood such as arise from sibling jealousy and disappointment in parents. Such feelings were often reported in the interviews of low scorers at the Clinic.
Variable VI: Cues Referring to the Patient's Character Structure. The reliabilities here were 74 per cent (rater A with control rater) and 78 per cent (for rater A with rater B). These agreements are statistically quite accept- able. Rater A also achieved quite high agreement withE score (So per cent), while the control rater's agreement with E was only 62 per cent. The control rater's judgments of the low scorers showed much higher agreement (7r percent) than did her ratings of the high scorers (52 per cent). Her reliability was also lower for the high group. This could be related to the fact that the manual gave more detailed and concrete instructions and examples for the
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94?
"low" characteristics than for the "high" ones. This probably penalized the control rater much more than rater A, because the latter was already very familiar with the concepts and their application to interview material. It seems likely that the control rater's judgments would have shown much greater relationship to E had she had more training (in applying psycho- analytic concepts in general and the present variables in particular).
The syndrome of traits to be included in rating variable VI, were discussed in the scoring manual above (Section F, 2 ). They included:?
For high scorers
r. countercathectic defenses: re- action formations, projection, particularly anal reaction forma- tions for women, counteraction of passivity for men
2. lackofconcernwithlove-objects
3? extra- and impunitiveness 4? externalized superego
For low scorers
r. other defenses: particularly sub- limations into artistic, intellec- tual, humanitarian interests and activities
2. oral-dependent-love-seeking at- titude; nurturance, concern about being rejected
3? intrapunitiveness; masochism 4? internalized superego
These variables, of course, are identical with some of those used in the study of personality by means of the questionnaire and clinical techniques described earlier in the book. The detailed case studies of Clinic patients, the results of the Projective Questions for our group, and many of the State- ments of Complaint showed that these variables were just as valuable for dis- tinguishing high and low scores in this group as they were in the case of other groups. It is, of course, impossible to form, on the basis of the short Statements of Complaint alone, a personality picture of patients in which all of these characteristics appear. Therefore the reader, going over the examples of these Statements and a few selected case studies in the following section, may not be convinced, particularly since only brief outlines of the cases were given to illustrate the symptomatology, important genetic factors, and a few other characteristics common to a whole group of patients in the high and low quartiles. Many of the details about the patients' relationships to others and to their work were omitted there. Still, the reader will find striking differ- ences between low and high scorers by paying attention to the cues as defined above. Perhaps the first group of variables, namely the nature of defenses, will not become so apparent from the interview fragments selected for presentation. They will be illustrated primarily by the brief case examples included also in the following section. The complete material, as given to the raters, did offer more cues in this direction. Particularly striking was the frequency with which the low-scoring subjects (but hardly ever high-scor- ing ones) spoke about the interference of their symptoms with their work,
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rhich was in this connection described in such a way that one could infer the atient's true involvement in his work. A striking proportion of the low :orers had artistic occupations or interests.
The most frequent sign of trait no. 2 in our examples, lies in the fre- uency with which the low scorers refer in some way to their relationships ) other people, to concern about being rejected, and to their own shortcom- lgs in interpersonal relationships, quite in contrast to the high scorers.
The character syndrome intrapunitiveness-masochism-strong internalized 1perego is illustrated by several of the examples of low scorers, particularly 1e cases with neurotic depressions and inferiority feelings, but also by the ~If-critical attitude with which the low scorers report their difficulties. The reat frankness with which many of them expose their weaknesses or spon- meously talk about their childhood sufferings also perhaps expresses their dependent) wish to receive sympathy from the interviewer, as well as a esire to appease their strict superegos ("If I confess everything now, I won't ave to feel quite as guilty as I would if you discovered these things about 1e later. ")
Variable VII: Predominant Types of Symptoms. The two lists of vtnptoms are given in Section F, 2. The reliabilities for this category were tatistically acceptable (around So per cent) and the relationship to E was elatively high with all raters (73-85 per cent). According to these find- 1gS, the symptoms in List A characterize the high-scoring group, those in ,ist B predominate in the low-scoring group. The symptomatology of the cigh- and low-scoring groups will be presented and discussed in more detail 1 the following section which deals with the clinical pictures and personali- ies of the subjects. There, material gathered by the various techniques em- 1loyed in this study will be utilized and the discussion illustrated by a number 1f case examples.
6. SUMMARY
Before turning to the clinical section, however, we may summarize and liscuss the findings of the rating technique.
1. It was possible to predict standing on the E scale from a small section of subject's first psychiatric interview, dealing almost exclusively with the ubject's symptoms. This shows again how strongly ethnocentrism is cor-
elated with personality dynamics.
2. In order to test the thesis that the differences between the high- and
ow-scoring groups could be described by means of the variables described . hove, 7 control raters, each rating only one variable, were employed. Un- ortunately, these raters were not quite familiar enough with the meaning nd application of psychoanalytic concepts. In spite of this, an average ? eliability of 77 per cent between rater A (a staff member of the study) and ?
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the control raters was obtained. This figure is statistically acceptable for our purpose and indicates that the ratings by raters A and B were not based merely on comparisons of the interviews with a general "apperceptive mass" acquired in their experience with high and low scorers, but were actually based on the variables as here described. The average agreement for A (and also for B) between ratings of the single variables and E score was around 77 per cent; the corresponding figure for the control raters was only 65 per cent. However, when composite scores of highness-lowness were com- puted (derived from all 7 independent control ratings), the agreement with E was 75 per cent. This indicates that the variables show significant relation- ships toE, although we cannot say just how well one could predict E from any one of the single variables. The percentage-agreements of A's ratings with E score may have been raised somewhat? by previous experience with high- and low-scoring subjects and by the halo effect. The control raters' pre- dictions are certainly not as good as they could be, due to relative lack of training. From a theoretical point of view, the actual degree to which the relationships between E and each of the single variables exceed chance, is of little importance. Obviously all of the variables overlap. They probably represent various aspects of one or of a very few more basic personality factors.
G. CLINICAL PICTURES AND PERSONALITIES OF HIGH AND LOW SCORERS
1. THE HIGH SCORERS
Probably any one of the symptoms listed under A ("high") in Category VII, such as physical anxiety symptoms, hypochondriacal fears, stomach ul- cers (men), could be found in low-scoring subjects-and depression, tiredness, conscious conflict, and the like, in high scorers. However, the manifestations in List A and in List B seem to form syndromes which differentiated well between our two groups. The various symptoms in each syndrome have certain common characteristics. Even the control rater who had little train- ing in psychoanalytic or other dynamic theories sensed this relatedness. It helped her in the rating task because it was possible for her to form "whole impressions" of the patients, using the various single symptoms as alternative cues.
In comparing the various symptoms mentioned in one list with those men- tioned in the other, it becomes clear that the main difference between them consists in the way less acceptable parts of the personality are handled by the ego. In the high scorers the sources of disturbance-aggressive impulses, for
? instance-are seen as "outside" the self or other means are used to deny their true significance. Anxiety is displaced from the inner conflicts themselves
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to the body, or it appears in consciousness without the conflicts to which it belongs; or countercathective defenses are used, producing compulsive fea- tures or psychosomatic manifestations such as stomach ulcers (men). When impulses do begin to break through, they often do so in the form of violent outbursts, "spells," or tantrums, or they lead to a feeling of not being oneself.
It is this strenuous denial of many of one's impulses and the attempt at seeing everything unacceptable as outside the self, which seems to be the common denominator for most of the content of List A in Category VII. This is, in essence, the tendency-so common in high scorers-to keep things ego- alien. The same general character tendency, it seems, is expressed in extra- punitiveness and in other ways described elsewhere in the present volume. Once again, the findings on Clinic patients confirm what was found to be true in the Study's sample of the general population (Chapter XII).
a. HIGH-SCORING MEN. In order to illustrate the clinical pictures in high- scoring men a few case examples will be given here.
The first patient is a middle-aged businessman. In his first psychiatric inter- view he stated that he had "been fighting a nervous breakdown. " He com- plained of tremors, sweating, fatigue, polyuria, intestinal gas, spells of panic, and a tendency to cry. He said that his symptoms first appeared when he heard how much temporary alimony he had to pay. Then "something snapped in my head. " This condition had improved for a while, after some medical treatment, but reappeared after the patient's business license was suspended for a short time because of certain irregularities.
In the course of psychotherapy the patient was superficially cooperative, came on time, and was particularly polite to the therapist but could not enter into the therapeutic relationship. He offered several times to take the woman therapist to an elegant place for dinner. When speaking about himself, the patient dwelled merely on his somatic complaints in a hypochondriacal way and refused to give up the idea that his trouble was of physiological origin, requiring medical treatment. At the therapist's request, the patient told about his life experiences. He used this situation mainly to impress the therapist with stories of his business success and of his successful and in- fluential friends, but it became apparent that he had no genuine attachments to anyone. After some months both patient and therapist felt that treatment should be discontinued for lack of progress.
This patient's character and history point towards anal problems (reten- tion). Castration anxiety is experienced in terms of a fear of "losing some- thing" or "having to give up something. " His strong anxiety and underlying weakness is unsuccessfully cloaked by a masculine fac;ade which, in this case, centers around the idea of being a "successful businessman. " His relations to others are weak and egocentric. His externalized superego does not pre- vent him from trying slightly illegal means for reaching success. When his ego is threatened by some "loss" or lack of success, his anxiety is increased.
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In such a situation he becomes aware of anxiety without much content. He focuses on the physiological symptoms of anxiety, becomes even more anxious, then seeks medical treatment.
This particular type of high-scoring man was not very frequent in the Clinic group. Probably it is more frequent in medical clinics or in the practice of private physicians. The same pattern of underlying weakness and castra- tion anxiety covered by a masculine fa~ade was, however, found in most other high-scoring men patients, some with more, some with less compulsive char- acters. In some, unconscious homosexual conflicts were especially important. And paranoid trends were not uncommon. One group of high-scoring patients had few or no compulsive features but more marked phobic trends. These cases, too, had much "vague anxiety," were focused often on the physical anxiety symptoms such as tremors, and so forth, and showed some hypo- chondriacal concern.
An example of this latter type is a young veteran who suffered from a com- mon type of combat neurosis consisting of severe tremors and vague anxiety whenever he engaged in the least strenuous activity. This patient's ship had been torpedoed and the patient (who could not swim) had had to spend an hour on a leaky raft. At the time he had felt little fear. A month later, when on shore in a hotel, symptoms appeared suddenly, apparently without any precipitating cause. The patient had always suffered from mild phobias- being afraid of guns, bumblebees, snakes, hypodermics and, occasionally, of crowds and gatherings of strangers. However, "toughness" stood out in his personality. He had always had "crazy dreams," lately severe night- mares. In a recent one, four men in full military gear, including guns, had taken a blood test on him and a group of friends. They did it roughly and blood streamed down his arm.
This dream makes one wonder whether the battle incident in itself pre- cipitated the acute anxiety state. It seems more likely that the actual danger situation on the raft only contributed by temporarily decreasing the ego's ability to deal with other conflicts, possibly of a homosexual nature, that were activated by the situation in the service.
As in the case of several high-scoring male interviewees, the parents died when the patient was young. From the age of 12 on, the subject and his older brother were raised by the two older sisters. Little material on childhood history was recorded by the therapist. Of the family relationships we know only that the patient had, at the time of his treatment, warm feelings for his brother who, he said, bullied him in childhood to some extent. The patient still spoke with resentment of his sisters, who "dominated" him and whose guardianship he resented.
The patient's symptoms disappeared after six interviews in which his fam- ily relationships were discussed. He was also given explanations of the psy- chological and physiological mechanisms in fear and read some mental
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hygiene literature on this poirit. This, he said, had been helpful because it showed him "what our minds are made up of. "
Our last example is concerned with another type of case with a very in- fantile personality, who had had a schizophrenic episode in the service and was diagnosed as a "schizophrenia, simple type. " He said in his statement of complaint that he came to the Clinic "because I want to be natural again. " He felt that a few years ago he had "a good personality, but that is gone now. " He complained of lack of interest in anything, inability to concentrate or to enjoy anything, of "nervousness," "restlessness," and a "depressed and dazed feeling. " He couldn't "make friends or get acquainted. " He found it very hard to keep a job.
The patient, a 26-year-old man who lived at home with his father, had no friends, no girl friend, and no idea what he would like to do. He felt timid, very discouraged, empty, and utterly lonely. His relationships to his family were shallow and frustrating. The patient was the second of six siblings-he had one older brother, four younger sisters. His mother was committed to a mental institution when the patient was 10 years old. The children were raised in different foster homes and had little contact with one another. He felt lonely and unhappy. When interviewed, the patient could not even give the exact ages of his younger sisters, but said, "I miss my family. " The rela- tionship to his father was very disturbing to the patient, who found it some- what hard to admit this. The father was a strict Catholic and a punitive person with a bad temper, who had little understanding of the patient. He told his son that he would leave him if he could not stay at his present job. He also advised the subject to avoid psychiatrists and consult the priest instead. The patient seemed to be afraid of, and submissive to, his father in most respects, and had much underlying hostility toward him.
This man made high scores on the E and F scales, a middle score on PEC. The interview disclosed that the patient had no idea about most current issues. His prejudice, as expressed in the questionnaire, seemed to be related in part to his uncritical acceptance of all kinds of cliches about outgroups and to a general underlying hostility and a feeling of futility and threatening chaos. One of his main ideas was the importance of segregation of all kinds of minority groups "to avoid fights. " He felt "there will be trouble" and that "the country is going to the dogs. " Almost his only specific accusation against outgroups was that Negroes are inferior and aggressive. (At the same time, the patient said that he was the only white orderly in the military hos- pital who did not mind waiting on Negro patients. Perhaps this was due to an "ingratiation mechanism" which also made it possible for the patient to "get along" with his father. )
The following statements of complaint by high-scoring men may serve to illustrate further the personality trends discussed earlier.
One subject came to the hospital for gastro-intestinal study in connection
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with a project in psychosomatic medicine. He said he had suffered from stomach ulcers for fifteen years, complained of "nervousness and depressed attitude. " He had done much worrying about his stomach. His nervousness ? had markedly increased since his wife was operated on for thyroid trouble. Also, living with in-laws had been trying.
Another patient, who had been diagnosed as a "psychopathic personality with homosexuality and psychosomatic features," gave the following story in his first interview. Tension, headaches, "peculiar feelings," jumpiness, gas pains, and fear of being attacked. The symptoms appeared after an appendec- tomy a year earlier. Since then he had been afraid that a certain person would do him physical harm. "Shortly after that I was in a car accident and the same fellow tried to harm me. I didn't feel strong enough to protect myself. "
A third case was diagnosed "psychopathic personality with pathological sexuality and neurotic trends. " He was suspected of having duodenal ulcers, but no diagnosis had been made. The court had committed this patient to the hospital because he had exposed himself sexually to a small girl. The record of the first interview runs as follows:
The patient doesn't know why he does it. Relates a long history of sexual pre- occupations after being warned by his brother about masturbation and relations with girls. Has had fights when he has felt that someone was making fun of him or that something was due him and was being refused. Says he has always been rather close-mouthed, doesn't like to ask favors of anyone, and doesn't want to be indebted to anyone. Three years ago he noticed that his ability to concentrate and to think fast was somewhat impaired. His job as an oil driller necessitated keen coordination and he was responsible for several injuries to the ground crew for which he subsequently blamed himself and felt that he could have prevented them if he had been more on his toes. Decided to give up oil drilling, became a welder. The patient confessed and stated that he was guilty of sexual exposure on one occasion but vigorously denied the others. The incident occurred when he was driving to work early in the morning, and the next thing he remembers was some- time in the afternoon. He recalls having exposed himself to a young girl on the corner, offering her a nickel to play with his penis. He became violently upset over this, felt that he had been working too hard, and took a week's vacation. Had been working fifteen or sixteen hours daily.
A fourth example is afforded by a high-scoring man diagnosed as "psy- choneurosis, anxiety state" whose statement of complaint was as follows:
Rapid breathing, pain over precordium, anxiety, and tension.
Patient states he does not know when his trouble started but has never felt well since a car ac- cident five years ago, when he fractured two ribs and struck his head. Developed headaches which came on if he had been worrying. His work, and especially the union men working under him have irritated him greatly. An increasing source of aggravation has been trouble with the production in the factory. Since the last summer vacation in the mountains he has developed more breathlessness, vomit- ing, diarrhea, some headaches, dreams of a senseless, disagreeable character. Symp- toms reappear when he returns to work.
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In the final example the diag~osis was "psychoneurosis, mixed, obsessive, compulsive and anxiety features, alcohol addiction," and the statement of complaint:
Being nervous and drinking too much. "I am afraid I'm going crazy. " Patient says that prior to four years ago he was perfectly well. Following a ball game, when he was home alone, minding the baby, he suffered a sudden onset of fear with profuse perspiration, palpitation, and trembling. He was afraid that he might harm himself or the child in some way. The doctor told him it was just nervousness and gave him phenobarbitol. Since that time he has had many such attacks, but not as severe. Can't account for the episodes. About one year ago he found that one shot of whiskey would make him "normal again. " This progressed slowly, building up to a pint a day and ever since. Since taking alcohol, he has been able to cut down the phenobarbitol almost entirely. He says he never gets completely drunk, but cannot get along without drinking. Realizes he is taking more and more and that this is quite expensive. The patient is anxious to stop drinking and to work out his problem. States there is no problem in his family relations.
b. HIGH-SCORING WoMEN. The high-scoring women showed the same types of anxiety and hypochondriacal symptoms as did the men; sometimes these appeared in more compulsive, sometimes in "phobic," sometimes in schizoid personalities. Many of them suffered from "spells," either of anxiety and/or of hyperventilation symptoms and loss of consciousness or of tension
. and temper outbursts: In some, all of these features were present. The following statements of complaints are typical:
Nervous attacks, easily upset. For three years. Attacks of confusion, tingling, tremors for eighteen months. The nervous spell consists of dizzy feeling in her head leading almost to unconsciousness, numbness, and tingling in her extremities. Breathing at the onset is fast and the heart starts beating fast. The symptoms began to appear after husband was shipped overseas. Husband is described as personally and sexually compatible. Questioning brought out, however, that there is some friction because he is not considerate enough of the children.
(Essentially the same physical symptoms as in the first example were related. ) Also, the patient was terrified of dying of heart failure during her spells. She got very tense and irritable at the children and occasionally squeezed their throats until she regained composure. Alarmed at these tendencies, the patient sought help.
(Same physical symptoms as above. ) Panic, crying spells, sexual difficulties, and jealousy of husband. Spells started three and a half years ago, when she felt "an electric shock passing from the bottom of her feet to her head. " After this fol-
lowed the first "spell. " They have recurred two or three times a day since. The patient is afraid of death during a spell, of heart trouble, of cancer, of "losing my mind," and of harming her children during a spell.
The following case is the only one of this type that was interviewed. The patient was a young, lower middle-class housewife with two children. Her husband was a semi-skilled worker who had been on the night shift since their marriage ten years ago. Patient feared the dark as a child and had never liked staying home at night alone, but a few months ago her anxiety became
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acute. She locked all windows and doors at night, for fear someone might come in and attack her and the children. Two months ago, while dozing off at night, she awoke with a sudden anxiety attack and then lost conscious- ness. Every day ? since then she has become very tense and has had pains in the cords of her neck. She has had a feeling of being hot and cold at the same time, and a queer sinking feeling. Occasionally she has had spells of shaking and fainting. She has been able to call someone to help her each time just before losing consciousness. At such times she also has had fits of screaming. Afterwards, she has had amnesia for part of the event. The following history material and personality picture was gleaned from inter- views, T. A. T. stories, and from a series of dreams reported during her therapy.
The symptoms refer primarily to a present conflict about the patient's dis- satisfaction with her marriage. This conflict is patterned after an earlier one involving her relationships to her family, particularly one brother.
The patient and her two older brothers were raised on a rather isolated farm. They had few friends and even in adolescence the patient was not permitted to go out much nor to have dates or witness boys' athletic events unchaperoned. The parents were Swiss Catholic immigrants who adhered strictly to their old-world mores. The mother seems to have been particularly severe with regard to toilet and cleanliness training-as indicated also by her present treatment of the grandchildren-and to have completely suppressed. the children's noisiness and overt hostility. The sexual taboos were strictly observed; the children were trained to be extremely modest and were given no sex instruction. This type of training has produced a number of reaction formations in the patient, e. g. , excessive concern with neatness, punctuality, obedience, and modesty. Aside from these facts, it is difficult to form a con- crete realistic picture of the personalities and relationships in the subject's family, as her descriptions were so extremely idealized. She described the father as an old-fashioned but very jovial and mild man; the mother as a nervous and somewhat ailing but hard-working, generous, and kind woman and good mother; the brothers as particularly nice and good natured. The patient claimed she "had a lot of fun" in childhood, and "never fought" with the two brothers. Similarly, she insisted that there was nothing wrong in her relationship with her husband except for his working nights, for which he is not to blame. She said that sexual relations, though often somewhat hurried, were usually satisfactory-though she occasionally did not achieve an orgasm.
The dreams and T. A. T. revealed, however, that the patient had a great deal of unconscious hostility towards her husband, as well as towards her mother, her favorite brother, and men in general, who were represented as aggressive and sexually brutal. This unconscious imagery of men as "at- tackers" was expressed consciously in her thinking about certain outgroups such as Negroes and Mexicans. The dreams also suggest a conflict over sexual
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and oral-aggressive impulses directed towards men. The contexts in which the orality and aggression appeared (smashing snakes, biting into chicken drumsticks, etc. ) suggest infantile wishes to bite, destroy and incorporate a penis. Dangerous, electrically charged wire fences belonging to an enclosure for chickens (such as existed on her parents' farm) formed a recurrent theme; the patient unwittingly climbed a fence or touched it, with the result- ing sensation of "being shaken" and of inability to tear herself away from the fence until the current was shut off. Here, it seems, there is reenactment of fears connected with the gratification of infantile wishes-probably sexual ones. This is likely also to be the meaning of her shaking and fainting spells, of which the dream scene is reminiscent.
To this subject, the expression of hostility represented a special problem. She could not admit any aggression towards her husband or family, inhibit- ing most expressions of anger and irritation behind a fac;ade of submissive compliance and somewhat forced cheerfulness. In therapy it was revealed that her shaking and fainting spells always followed incidents in which a man provoked her anger by acting in a deprecating and implicitly aggressive and demanding manner, while she retained a calm and good-humored at- titude. Thus, the first spell occurred after a card game in which her husband called her attention to an ace she had overlooked. She said that ordinarily she would have become angry with her husband, but this time she "laughed it off. " Other spells have occurred after she was asked to pay a bill which had already been paid and after she was told she would have to pay more for an article than the price previously agreed upon. In both cases she felt no anger at the time but had a "spell" later.
This case can be described as an anxiety hysteria in which compulsive trends play a role, and in which conflicts about hostile impulses are par- ticularly important. The other cases with anxiety and "nervous spells" are probably dynamically similar. There was one case with a psychogenic pa- ralysis of the right arm and face. This woman had a very rigid character and some compulsive traits. She, too, had extreme unconscious hostility towards men, particularly her former husband. The symptom appeared after she had struck her brother, to whom she had an ambivalent erotic attachment, when he made sexual advances towards her.
Another personality pattern found among the ethnocentric subjects might be called the constricted infantile schizoid type. Here, too, compulsive traits are an important part of the picture. Some of these cases, when acutely dis- turbed, had feelings of depersonalization and apathy. The following case is an example:
The patient was a 27-year-old college graduate who had been married about a year and had just had a baby. She looked and acted younger than her age, and generally made the impression of a naive, very "good little girl. " She was very inhibited-in the expression of both sensuality and aggression-
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and her ego was occupied to a very large extent with maintammg order, cleanliness, control, and a good fas;ade. She did this by limiting her interests and concentrating on religion and her duties. The latter were carried out efficiently, and this gave her a sense of satisfaction. Before her marriage she achieved this kind of satisfaction through secretarial work; at the time of admission to the Clinic she was interested exclusively in housekeeping.
The patient described her father as a "stern disciplinarian" whom she had always feared. She resented his treatment of her husband of whom he did not approve, but she was unable to admit this resentment. She described her mother in the familiar idealized terms and said: "I have always respected her. " She had several brothers with whom she competed for love and ap- proval, and, like many of our high-scoring women, she ended this competi- tion by accepting-on the surface-a completely feminine and submissive role.
The husband, a social service worker, was still in the army, and so was not with the patient after the birth of the child. It was at this time that the patient began to feel "peculiar like in a fog" and as though she were "not quite my- self. " She was otiented in space and time but could not carry out some of the simplest tasks, in spite of very superior mental ability which, according to tests, had not been affected by her illness. Her physicians thought it best to have the patient join her husband at the earliest possible moment. She was thought well enough to travel alone with the baby. Unexpectedly, during the trip she had to change plans. This stumped her completely. She just sat down with her baby in the waiting room at the airport, quite lost and not able to ask for information nor to make arrangements for herself. She did not improve much after she had joined her husband. In going shopping, for in- stance, she would stand before the grocery shelves, unable to think of things to buy. The patient was very alarmed and depressed about her condition. In the hospital she kept repeating her complaints over and over, and said she feared she was going crazy and that she could not be helped.
The husband reported that the patient had changed in other respects too. Whereas she had been sexually rather frigid before the delivery, she all of a sudden became very passionate.
flospitalization and psychotherapy seemed to do little good. So the patient was discharged and brought in by her husband at intervals for electric shock treatments. After very few treatments the patient felt normal and both she and her husband felt that she was now less inhibited, warmer, and able to enjoy herself more.
At the present time the psychological meanings and effects of shock treat- ments are not sufficiently understood to permit theorizing concerning its role in this case. Its evaluation is rendered the more difficult by the fact that the patient had received and was receiving psychotherapy. The doctors' and husband's acceptance of her newly awakened sensuality may have helped
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the patient to accept this part ofherself, and this may have been an important factor in her improvement.
Another case of the same general type was a 24-year-old mother of two children. She too had an episode of depersonalization and forgetfulness fol- lowing the birth of the first child. This woman could have been taken for a naive high school girl. Her usual submissive and conventional "good girl" be- havior occasionally alternated with outbursts of anger and spite. She was a very dependent person with no ideas and opinions of her own and without interests outside of the domestic sphere. When her husband's support was withdrawn (because of illness) just after she had her second child, she suf- fered a paranoid schizophrenic episode, became afraid someone would harm her and the children, that her husband or relatives would take one of her daughters out and not bring her back.
Still another case was that of a girl who had always been a particularly con- scientious worker and who was completely submissive to her rigid, unsym- pathetic parents and aggressive older sister, without ever becoming aware of any resentment. When this girl was promoted to a job of considerable re- sponsibility she developed extreme headaches and entered a state of depres- sion and anxiety, in which she accused herself of being bad, thought people were looking at her, and feared she would lose her mind.
This girl and several other high-scoring women suffered, during the acute stages of their illness, from a mood disturbance which could only be de- scribed as "agitated depression. " (In some cases this was accompanied by suicidal ideas. ) These depressions, however, were different from those seen in the patients who were subject to periodic neurotic depressions. They were often accompanied by somewhat bizarre ideas and in general showed schizoid qualities. For this reason they were sometimes labeled schizo-affective reactions.
Few of these cases had the slightest idea of or interest in current issues and were very unsure of the few ideas they could voice during the interviews. Their ideologies about outgroups were meager, less elaborated, and even more naive and stereotyped than those of less disturbed high-scoring subjects. Their rejection of outgroups-in the abstract at least-was extremely strong, leading to very high prejudice scores and often to emotionally charged re- sponses during interviews such as "You wouldn't want to have a black baby, would you? " This is an expression of their particular ego weakness, necessitat- ing special efforts at creating and maintaining countercathexes.
2. THE LOW SCORERS
The pattern formed by the symptoms in List B of Category VII is dif- ferent. The unacceptable impulses-although not all conscious nor undis- guised-are more ego-assimilated and are perceived as part of the self. The
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low-scoring patients generally came to the Clinic with a particular psycho- logical problem they wanted to solve. They complained of certain conflicts or anxieties about some more or less definite idea or situation or were consciously dissatisfied with their sex role. Many of these are character neuroses. The "evil" was not sought outside but in the self. Elsewhere in the present volume it has been shown that high scorers on E are typically extrapunitive, while low scorers are intrapunitive. Intrapunitiveness has been understood as a sign of a strict but internalized superego and probably also of a somewhat masochistic character structure. The psychologically ill low scorers seem to show this tendency in exaggerated form: in (neurotic) depression, suicidal ideas, inferiority, and guilt feelings.
Their greater acceptance of their instinctual and fantasy lives and their relative independence from conventional restrictions give great variety, in- dividuality, and even bizarreness to the pathological ideas and behavior of these patients.
In some ways many of these patients (although by no means all of them) behaved in a way that is opposite to the cultural norm for their sex. Some of the men were shy, timid, passive, and dependent and had some interests more often found in women. Some of the women were aggressive, less inter- ested in home and family than in some occupational achievement. Homo- sexuality and sexual perversions were more freely admitted, and conflicts about such impulses were often quite conscious and undisguised. (This does not mean that the low scorers have more homosexual tendencies. There are probably just as many if not many more high scorers with such impulses. But in the latter case, these impulses and fantasies are strongly disguised and re- pressed. )
a. Low-scoRING MEN. The low scorers on E presented such a variety of complaints and clinical pictures that it is almost impossible to fit them into a few "types. " While some had psychoses or classical neuroses with anxiety- hysterical and compulsive symptoms, many cases presented character dis- orders which had come to the fore or were accentuated because of situational factors. An example of this type was a very dependent man, married to a more aggressive woman to whom he was very much attached and. sexually attracted. The relationship, always problematic, had become intolerable since the wife had a second child whom she rejected. The Clinic suggested foster-home placement for the child. The patient could not accept this nor could he decide to leave his famliy.
Broadly speaking, the low-scoring men were generally unaggressive, nur- turant, often somewhat withdrawn and inhibited socially. They came to the Clinic with depressions and conscious anxieties relating to problems of sex, work, or general adjustment. In contrast to the high-scoring men, the prob- lems as stated by these patients referred directly to their relationships to others. During the war a few of them suffered acute conflict about the prob-
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lem of participation, leading, in'a few cases, to self-inflicted injuries to avoid the draft, in others to conscientious objection. This was not primarily because of fear of physical injury or death but because of ideological reasons and a horror of being forced to kill.
An illustrative case is that of a young man of college age who had been in a camp for conscientious objectors. He was short and slight. His manner and speech betrayed much tension and self-consciousness. He was very unsure of himself and suffered somewhat from compulsive doubt and indecision. He had well-formed opinions about some subjects-such as the problems of minorities and pacifism-but in most areas he was quite uncertain, mentioning one opinion and then retreating when challenged by the interviewer, saying "I really don't know much about it yet-I have to read a lot more. " He was
keenly interested in politics and concerned about social progress. He realized that his occupational choice-to counsel people about their personal problems -stemmed from awareness of his own inner struggles and from his own desire to be helped.
The patient voluntarily sought help because of restlessness, anxiety, occa- sional depression, and inability to concentrate. He also had severe feelings of inadequacy, stage-fright, social anxiety, and several fears-of the dark, of physical injury, and of graveyards and mental institutions.
The patient's father was of lower-class origin with a grade-school educa- tion, who became a carpenter, then a farmer and minister in a fundamentalist church. He was a stern, dominating and punitive man with narrow, funda- mentalist and puritanical ideas, who made the children work hard on the farm and dealt out severe corporal punishment.
The results here agree with the general finding of the study as a whole that low scorers freely admit friction with and negative feelings towards their families, and in general are more aware of and more frank about conflict and affect. The high scorers gave smooth, bland histories and had idealized pictures of their families. This would rarely allow them to admit feelings of unhappiness and loneliness in childhood such as arise from sibling jealousy and disappointment in parents. Such feelings were often reported in the interviews of low scorers at the Clinic.
Variable VI: Cues Referring to the Patient's Character Structure. The reliabilities here were 74 per cent (rater A with control rater) and 78 per cent (for rater A with rater B). These agreements are statistically quite accept- able. Rater A also achieved quite high agreement withE score (So per cent), while the control rater's agreement with E was only 62 per cent. The control rater's judgments of the low scorers showed much higher agreement (7r percent) than did her ratings of the high scorers (52 per cent). Her reliability was also lower for the high group. This could be related to the fact that the manual gave more detailed and concrete instructions and examples for the
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94?
"low" characteristics than for the "high" ones. This probably penalized the control rater much more than rater A, because the latter was already very familiar with the concepts and their application to interview material. It seems likely that the control rater's judgments would have shown much greater relationship to E had she had more training (in applying psycho- analytic concepts in general and the present variables in particular).
The syndrome of traits to be included in rating variable VI, were discussed in the scoring manual above (Section F, 2 ). They included:?
For high scorers
r. countercathectic defenses: re- action formations, projection, particularly anal reaction forma- tions for women, counteraction of passivity for men
2. lackofconcernwithlove-objects
3? extra- and impunitiveness 4? externalized superego
For low scorers
r. other defenses: particularly sub- limations into artistic, intellec- tual, humanitarian interests and activities
2. oral-dependent-love-seeking at- titude; nurturance, concern about being rejected
3? intrapunitiveness; masochism 4? internalized superego
These variables, of course, are identical with some of those used in the study of personality by means of the questionnaire and clinical techniques described earlier in the book. The detailed case studies of Clinic patients, the results of the Projective Questions for our group, and many of the State- ments of Complaint showed that these variables were just as valuable for dis- tinguishing high and low scores in this group as they were in the case of other groups. It is, of course, impossible to form, on the basis of the short Statements of Complaint alone, a personality picture of patients in which all of these characteristics appear. Therefore the reader, going over the examples of these Statements and a few selected case studies in the following section, may not be convinced, particularly since only brief outlines of the cases were given to illustrate the symptomatology, important genetic factors, and a few other characteristics common to a whole group of patients in the high and low quartiles. Many of the details about the patients' relationships to others and to their work were omitted there. Still, the reader will find striking differ- ences between low and high scorers by paying attention to the cues as defined above. Perhaps the first group of variables, namely the nature of defenses, will not become so apparent from the interview fragments selected for presentation. They will be illustrated primarily by the brief case examples included also in the following section. The complete material, as given to the raters, did offer more cues in this direction. Particularly striking was the frequency with which the low-scoring subjects (but hardly ever high-scor- ing ones) spoke about the interference of their symptoms with their work,
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rhich was in this connection described in such a way that one could infer the atient's true involvement in his work. A striking proportion of the low :orers had artistic occupations or interests.
The most frequent sign of trait no. 2 in our examples, lies in the fre- uency with which the low scorers refer in some way to their relationships ) other people, to concern about being rejected, and to their own shortcom- lgs in interpersonal relationships, quite in contrast to the high scorers.
The character syndrome intrapunitiveness-masochism-strong internalized 1perego is illustrated by several of the examples of low scorers, particularly 1e cases with neurotic depressions and inferiority feelings, but also by the ~If-critical attitude with which the low scorers report their difficulties. The reat frankness with which many of them expose their weaknesses or spon- meously talk about their childhood sufferings also perhaps expresses their dependent) wish to receive sympathy from the interviewer, as well as a esire to appease their strict superegos ("If I confess everything now, I won't ave to feel quite as guilty as I would if you discovered these things about 1e later. ")
Variable VII: Predominant Types of Symptoms. The two lists of vtnptoms are given in Section F, 2. The reliabilities for this category were tatistically acceptable (around So per cent) and the relationship to E was elatively high with all raters (73-85 per cent). According to these find- 1gS, the symptoms in List A characterize the high-scoring group, those in ,ist B predominate in the low-scoring group. The symptomatology of the cigh- and low-scoring groups will be presented and discussed in more detail 1 the following section which deals with the clinical pictures and personali- ies of the subjects. There, material gathered by the various techniques em- 1loyed in this study will be utilized and the discussion illustrated by a number 1f case examples.
6. SUMMARY
Before turning to the clinical section, however, we may summarize and liscuss the findings of the rating technique.
1. It was possible to predict standing on the E scale from a small section of subject's first psychiatric interview, dealing almost exclusively with the ubject's symptoms. This shows again how strongly ethnocentrism is cor-
elated with personality dynamics.
2. In order to test the thesis that the differences between the high- and
ow-scoring groups could be described by means of the variables described . hove, 7 control raters, each rating only one variable, were employed. Un- ortunately, these raters were not quite familiar enough with the meaning nd application of psychoanalytic concepts. In spite of this, an average ? eliability of 77 per cent between rater A (a staff member of the study) and ?
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the control raters was obtained. This figure is statistically acceptable for our purpose and indicates that the ratings by raters A and B were not based merely on comparisons of the interviews with a general "apperceptive mass" acquired in their experience with high and low scorers, but were actually based on the variables as here described. The average agreement for A (and also for B) between ratings of the single variables and E score was around 77 per cent; the corresponding figure for the control raters was only 65 per cent. However, when composite scores of highness-lowness were com- puted (derived from all 7 independent control ratings), the agreement with E was 75 per cent. This indicates that the variables show significant relation- ships toE, although we cannot say just how well one could predict E from any one of the single variables. The percentage-agreements of A's ratings with E score may have been raised somewhat? by previous experience with high- and low-scoring subjects and by the halo effect. The control raters' pre- dictions are certainly not as good as they could be, due to relative lack of training. From a theoretical point of view, the actual degree to which the relationships between E and each of the single variables exceed chance, is of little importance. Obviously all of the variables overlap. They probably represent various aspects of one or of a very few more basic personality factors.
G. CLINICAL PICTURES AND PERSONALITIES OF HIGH AND LOW SCORERS
1. THE HIGH SCORERS
Probably any one of the symptoms listed under A ("high") in Category VII, such as physical anxiety symptoms, hypochondriacal fears, stomach ul- cers (men), could be found in low-scoring subjects-and depression, tiredness, conscious conflict, and the like, in high scorers. However, the manifestations in List A and in List B seem to form syndromes which differentiated well between our two groups. The various symptoms in each syndrome have certain common characteristics. Even the control rater who had little train- ing in psychoanalytic or other dynamic theories sensed this relatedness. It helped her in the rating task because it was possible for her to form "whole impressions" of the patients, using the various single symptoms as alternative cues.
In comparing the various symptoms mentioned in one list with those men- tioned in the other, it becomes clear that the main difference between them consists in the way less acceptable parts of the personality are handled by the ego. In the high scorers the sources of disturbance-aggressive impulses, for
? instance-are seen as "outside" the self or other means are used to deny their true significance. Anxiety is displaced from the inner conflicts themselves
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to the body, or it appears in consciousness without the conflicts to which it belongs; or countercathective defenses are used, producing compulsive fea- tures or psychosomatic manifestations such as stomach ulcers (men). When impulses do begin to break through, they often do so in the form of violent outbursts, "spells," or tantrums, or they lead to a feeling of not being oneself.
It is this strenuous denial of many of one's impulses and the attempt at seeing everything unacceptable as outside the self, which seems to be the common denominator for most of the content of List A in Category VII. This is, in essence, the tendency-so common in high scorers-to keep things ego- alien. The same general character tendency, it seems, is expressed in extra- punitiveness and in other ways described elsewhere in the present volume. Once again, the findings on Clinic patients confirm what was found to be true in the Study's sample of the general population (Chapter XII).
a. HIGH-SCORING MEN. In order to illustrate the clinical pictures in high- scoring men a few case examples will be given here.
The first patient is a middle-aged businessman. In his first psychiatric inter- view he stated that he had "been fighting a nervous breakdown. " He com- plained of tremors, sweating, fatigue, polyuria, intestinal gas, spells of panic, and a tendency to cry. He said that his symptoms first appeared when he heard how much temporary alimony he had to pay. Then "something snapped in my head. " This condition had improved for a while, after some medical treatment, but reappeared after the patient's business license was suspended for a short time because of certain irregularities.
In the course of psychotherapy the patient was superficially cooperative, came on time, and was particularly polite to the therapist but could not enter into the therapeutic relationship. He offered several times to take the woman therapist to an elegant place for dinner. When speaking about himself, the patient dwelled merely on his somatic complaints in a hypochondriacal way and refused to give up the idea that his trouble was of physiological origin, requiring medical treatment. At the therapist's request, the patient told about his life experiences. He used this situation mainly to impress the therapist with stories of his business success and of his successful and in- fluential friends, but it became apparent that he had no genuine attachments to anyone. After some months both patient and therapist felt that treatment should be discontinued for lack of progress.
This patient's character and history point towards anal problems (reten- tion). Castration anxiety is experienced in terms of a fear of "losing some- thing" or "having to give up something. " His strong anxiety and underlying weakness is unsuccessfully cloaked by a masculine fac;ade which, in this case, centers around the idea of being a "successful businessman. " His relations to others are weak and egocentric. His externalized superego does not pre- vent him from trying slightly illegal means for reaching success. When his ego is threatened by some "loss" or lack of success, his anxiety is increased.
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In such a situation he becomes aware of anxiety without much content. He focuses on the physiological symptoms of anxiety, becomes even more anxious, then seeks medical treatment.
This particular type of high-scoring man was not very frequent in the Clinic group. Probably it is more frequent in medical clinics or in the practice of private physicians. The same pattern of underlying weakness and castra- tion anxiety covered by a masculine fa~ade was, however, found in most other high-scoring men patients, some with more, some with less compulsive char- acters. In some, unconscious homosexual conflicts were especially important. And paranoid trends were not uncommon. One group of high-scoring patients had few or no compulsive features but more marked phobic trends. These cases, too, had much "vague anxiety," were focused often on the physical anxiety symptoms such as tremors, and so forth, and showed some hypo- chondriacal concern.
An example of this latter type is a young veteran who suffered from a com- mon type of combat neurosis consisting of severe tremors and vague anxiety whenever he engaged in the least strenuous activity. This patient's ship had been torpedoed and the patient (who could not swim) had had to spend an hour on a leaky raft. At the time he had felt little fear. A month later, when on shore in a hotel, symptoms appeared suddenly, apparently without any precipitating cause. The patient had always suffered from mild phobias- being afraid of guns, bumblebees, snakes, hypodermics and, occasionally, of crowds and gatherings of strangers. However, "toughness" stood out in his personality. He had always had "crazy dreams," lately severe night- mares. In a recent one, four men in full military gear, including guns, had taken a blood test on him and a group of friends. They did it roughly and blood streamed down his arm.
This dream makes one wonder whether the battle incident in itself pre- cipitated the acute anxiety state. It seems more likely that the actual danger situation on the raft only contributed by temporarily decreasing the ego's ability to deal with other conflicts, possibly of a homosexual nature, that were activated by the situation in the service.
As in the case of several high-scoring male interviewees, the parents died when the patient was young. From the age of 12 on, the subject and his older brother were raised by the two older sisters. Little material on childhood history was recorded by the therapist. Of the family relationships we know only that the patient had, at the time of his treatment, warm feelings for his brother who, he said, bullied him in childhood to some extent. The patient still spoke with resentment of his sisters, who "dominated" him and whose guardianship he resented.
The patient's symptoms disappeared after six interviews in which his fam- ily relationships were discussed. He was also given explanations of the psy- chological and physiological mechanisms in fear and read some mental
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hygiene literature on this poirit. This, he said, had been helpful because it showed him "what our minds are made up of. "
Our last example is concerned with another type of case with a very in- fantile personality, who had had a schizophrenic episode in the service and was diagnosed as a "schizophrenia, simple type. " He said in his statement of complaint that he came to the Clinic "because I want to be natural again. " He felt that a few years ago he had "a good personality, but that is gone now. " He complained of lack of interest in anything, inability to concentrate or to enjoy anything, of "nervousness," "restlessness," and a "depressed and dazed feeling. " He couldn't "make friends or get acquainted. " He found it very hard to keep a job.
The patient, a 26-year-old man who lived at home with his father, had no friends, no girl friend, and no idea what he would like to do. He felt timid, very discouraged, empty, and utterly lonely. His relationships to his family were shallow and frustrating. The patient was the second of six siblings-he had one older brother, four younger sisters. His mother was committed to a mental institution when the patient was 10 years old. The children were raised in different foster homes and had little contact with one another. He felt lonely and unhappy. When interviewed, the patient could not even give the exact ages of his younger sisters, but said, "I miss my family. " The rela- tionship to his father was very disturbing to the patient, who found it some- what hard to admit this. The father was a strict Catholic and a punitive person with a bad temper, who had little understanding of the patient. He told his son that he would leave him if he could not stay at his present job. He also advised the subject to avoid psychiatrists and consult the priest instead. The patient seemed to be afraid of, and submissive to, his father in most respects, and had much underlying hostility toward him.
This man made high scores on the E and F scales, a middle score on PEC. The interview disclosed that the patient had no idea about most current issues. His prejudice, as expressed in the questionnaire, seemed to be related in part to his uncritical acceptance of all kinds of cliches about outgroups and to a general underlying hostility and a feeling of futility and threatening chaos. One of his main ideas was the importance of segregation of all kinds of minority groups "to avoid fights. " He felt "there will be trouble" and that "the country is going to the dogs. " Almost his only specific accusation against outgroups was that Negroes are inferior and aggressive. (At the same time, the patient said that he was the only white orderly in the military hos- pital who did not mind waiting on Negro patients. Perhaps this was due to an "ingratiation mechanism" which also made it possible for the patient to "get along" with his father. )
The following statements of complaint by high-scoring men may serve to illustrate further the personality trends discussed earlier.
One subject came to the hospital for gastro-intestinal study in connection
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with a project in psychosomatic medicine. He said he had suffered from stomach ulcers for fifteen years, complained of "nervousness and depressed attitude. " He had done much worrying about his stomach. His nervousness ? had markedly increased since his wife was operated on for thyroid trouble. Also, living with in-laws had been trying.
Another patient, who had been diagnosed as a "psychopathic personality with homosexuality and psychosomatic features," gave the following story in his first interview. Tension, headaches, "peculiar feelings," jumpiness, gas pains, and fear of being attacked. The symptoms appeared after an appendec- tomy a year earlier. Since then he had been afraid that a certain person would do him physical harm. "Shortly after that I was in a car accident and the same fellow tried to harm me. I didn't feel strong enough to protect myself. "
A third case was diagnosed "psychopathic personality with pathological sexuality and neurotic trends. " He was suspected of having duodenal ulcers, but no diagnosis had been made. The court had committed this patient to the hospital because he had exposed himself sexually to a small girl. The record of the first interview runs as follows:
The patient doesn't know why he does it. Relates a long history of sexual pre- occupations after being warned by his brother about masturbation and relations with girls. Has had fights when he has felt that someone was making fun of him or that something was due him and was being refused. Says he has always been rather close-mouthed, doesn't like to ask favors of anyone, and doesn't want to be indebted to anyone. Three years ago he noticed that his ability to concentrate and to think fast was somewhat impaired. His job as an oil driller necessitated keen coordination and he was responsible for several injuries to the ground crew for which he subsequently blamed himself and felt that he could have prevented them if he had been more on his toes. Decided to give up oil drilling, became a welder. The patient confessed and stated that he was guilty of sexual exposure on one occasion but vigorously denied the others. The incident occurred when he was driving to work early in the morning, and the next thing he remembers was some- time in the afternoon. He recalls having exposed himself to a young girl on the corner, offering her a nickel to play with his penis. He became violently upset over this, felt that he had been working too hard, and took a week's vacation. Had been working fifteen or sixteen hours daily.
A fourth example is afforded by a high-scoring man diagnosed as "psy- choneurosis, anxiety state" whose statement of complaint was as follows:
Rapid breathing, pain over precordium, anxiety, and tension.
Patient states he does not know when his trouble started but has never felt well since a car ac- cident five years ago, when he fractured two ribs and struck his head. Developed headaches which came on if he had been worrying. His work, and especially the union men working under him have irritated him greatly. An increasing source of aggravation has been trouble with the production in the factory. Since the last summer vacation in the mountains he has developed more breathlessness, vomit- ing, diarrhea, some headaches, dreams of a senseless, disagreeable character. Symp- toms reappear when he returns to work.
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In the final example the diag~osis was "psychoneurosis, mixed, obsessive, compulsive and anxiety features, alcohol addiction," and the statement of complaint:
Being nervous and drinking too much. "I am afraid I'm going crazy. " Patient says that prior to four years ago he was perfectly well. Following a ball game, when he was home alone, minding the baby, he suffered a sudden onset of fear with profuse perspiration, palpitation, and trembling. He was afraid that he might harm himself or the child in some way. The doctor told him it was just nervousness and gave him phenobarbitol. Since that time he has had many such attacks, but not as severe. Can't account for the episodes. About one year ago he found that one shot of whiskey would make him "normal again. " This progressed slowly, building up to a pint a day and ever since. Since taking alcohol, he has been able to cut down the phenobarbitol almost entirely. He says he never gets completely drunk, but cannot get along without drinking. Realizes he is taking more and more and that this is quite expensive. The patient is anxious to stop drinking and to work out his problem. States there is no problem in his family relations.
b. HIGH-SCORING WoMEN. The high-scoring women showed the same types of anxiety and hypochondriacal symptoms as did the men; sometimes these appeared in more compulsive, sometimes in "phobic," sometimes in schizoid personalities. Many of them suffered from "spells," either of anxiety and/or of hyperventilation symptoms and loss of consciousness or of tension
. and temper outbursts: In some, all of these features were present. The following statements of complaints are typical:
Nervous attacks, easily upset. For three years. Attacks of confusion, tingling, tremors for eighteen months. The nervous spell consists of dizzy feeling in her head leading almost to unconsciousness, numbness, and tingling in her extremities. Breathing at the onset is fast and the heart starts beating fast. The symptoms began to appear after husband was shipped overseas. Husband is described as personally and sexually compatible. Questioning brought out, however, that there is some friction because he is not considerate enough of the children.
(Essentially the same physical symptoms as in the first example were related. ) Also, the patient was terrified of dying of heart failure during her spells. She got very tense and irritable at the children and occasionally squeezed their throats until she regained composure. Alarmed at these tendencies, the patient sought help.
(Same physical symptoms as above. ) Panic, crying spells, sexual difficulties, and jealousy of husband. Spells started three and a half years ago, when she felt "an electric shock passing from the bottom of her feet to her head. " After this fol-
lowed the first "spell. " They have recurred two or three times a day since. The patient is afraid of death during a spell, of heart trouble, of cancer, of "losing my mind," and of harming her children during a spell.
The following case is the only one of this type that was interviewed. The patient was a young, lower middle-class housewife with two children. Her husband was a semi-skilled worker who had been on the night shift since their marriage ten years ago. Patient feared the dark as a child and had never liked staying home at night alone, but a few months ago her anxiety became
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acute. She locked all windows and doors at night, for fear someone might come in and attack her and the children. Two months ago, while dozing off at night, she awoke with a sudden anxiety attack and then lost conscious- ness. Every day ? since then she has become very tense and has had pains in the cords of her neck. She has had a feeling of being hot and cold at the same time, and a queer sinking feeling. Occasionally she has had spells of shaking and fainting. She has been able to call someone to help her each time just before losing consciousness. At such times she also has had fits of screaming. Afterwards, she has had amnesia for part of the event. The following history material and personality picture was gleaned from inter- views, T. A. T. stories, and from a series of dreams reported during her therapy.
The symptoms refer primarily to a present conflict about the patient's dis- satisfaction with her marriage. This conflict is patterned after an earlier one involving her relationships to her family, particularly one brother.
The patient and her two older brothers were raised on a rather isolated farm. They had few friends and even in adolescence the patient was not permitted to go out much nor to have dates or witness boys' athletic events unchaperoned. The parents were Swiss Catholic immigrants who adhered strictly to their old-world mores. The mother seems to have been particularly severe with regard to toilet and cleanliness training-as indicated also by her present treatment of the grandchildren-and to have completely suppressed. the children's noisiness and overt hostility. The sexual taboos were strictly observed; the children were trained to be extremely modest and were given no sex instruction. This type of training has produced a number of reaction formations in the patient, e. g. , excessive concern with neatness, punctuality, obedience, and modesty. Aside from these facts, it is difficult to form a con- crete realistic picture of the personalities and relationships in the subject's family, as her descriptions were so extremely idealized. She described the father as an old-fashioned but very jovial and mild man; the mother as a nervous and somewhat ailing but hard-working, generous, and kind woman and good mother; the brothers as particularly nice and good natured. The patient claimed she "had a lot of fun" in childhood, and "never fought" with the two brothers. Similarly, she insisted that there was nothing wrong in her relationship with her husband except for his working nights, for which he is not to blame. She said that sexual relations, though often somewhat hurried, were usually satisfactory-though she occasionally did not achieve an orgasm.
The dreams and T. A. T. revealed, however, that the patient had a great deal of unconscious hostility towards her husband, as well as towards her mother, her favorite brother, and men in general, who were represented as aggressive and sexually brutal. This unconscious imagery of men as "at- tackers" was expressed consciously in her thinking about certain outgroups such as Negroes and Mexicans. The dreams also suggest a conflict over sexual
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and oral-aggressive impulses directed towards men. The contexts in which the orality and aggression appeared (smashing snakes, biting into chicken drumsticks, etc. ) suggest infantile wishes to bite, destroy and incorporate a penis. Dangerous, electrically charged wire fences belonging to an enclosure for chickens (such as existed on her parents' farm) formed a recurrent theme; the patient unwittingly climbed a fence or touched it, with the result- ing sensation of "being shaken" and of inability to tear herself away from the fence until the current was shut off. Here, it seems, there is reenactment of fears connected with the gratification of infantile wishes-probably sexual ones. This is likely also to be the meaning of her shaking and fainting spells, of which the dream scene is reminiscent.
To this subject, the expression of hostility represented a special problem. She could not admit any aggression towards her husband or family, inhibit- ing most expressions of anger and irritation behind a fac;ade of submissive compliance and somewhat forced cheerfulness. In therapy it was revealed that her shaking and fainting spells always followed incidents in which a man provoked her anger by acting in a deprecating and implicitly aggressive and demanding manner, while she retained a calm and good-humored at- titude. Thus, the first spell occurred after a card game in which her husband called her attention to an ace she had overlooked. She said that ordinarily she would have become angry with her husband, but this time she "laughed it off. " Other spells have occurred after she was asked to pay a bill which had already been paid and after she was told she would have to pay more for an article than the price previously agreed upon. In both cases she felt no anger at the time but had a "spell" later.
This case can be described as an anxiety hysteria in which compulsive trends play a role, and in which conflicts about hostile impulses are par- ticularly important. The other cases with anxiety and "nervous spells" are probably dynamically similar. There was one case with a psychogenic pa- ralysis of the right arm and face. This woman had a very rigid character and some compulsive traits. She, too, had extreme unconscious hostility towards men, particularly her former husband. The symptom appeared after she had struck her brother, to whom she had an ambivalent erotic attachment, when he made sexual advances towards her.
Another personality pattern found among the ethnocentric subjects might be called the constricted infantile schizoid type. Here, too, compulsive traits are an important part of the picture. Some of these cases, when acutely dis- turbed, had feelings of depersonalization and apathy. The following case is an example:
The patient was a 27-year-old college graduate who had been married about a year and had just had a baby. She looked and acted younger than her age, and generally made the impression of a naive, very "good little girl. " She was very inhibited-in the expression of both sensuality and aggression-
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and her ego was occupied to a very large extent with maintammg order, cleanliness, control, and a good fas;ade. She did this by limiting her interests and concentrating on religion and her duties. The latter were carried out efficiently, and this gave her a sense of satisfaction. Before her marriage she achieved this kind of satisfaction through secretarial work; at the time of admission to the Clinic she was interested exclusively in housekeeping.
The patient described her father as a "stern disciplinarian" whom she had always feared. She resented his treatment of her husband of whom he did not approve, but she was unable to admit this resentment. She described her mother in the familiar idealized terms and said: "I have always respected her. " She had several brothers with whom she competed for love and ap- proval, and, like many of our high-scoring women, she ended this competi- tion by accepting-on the surface-a completely feminine and submissive role.
The husband, a social service worker, was still in the army, and so was not with the patient after the birth of the child. It was at this time that the patient began to feel "peculiar like in a fog" and as though she were "not quite my- self. " She was otiented in space and time but could not carry out some of the simplest tasks, in spite of very superior mental ability which, according to tests, had not been affected by her illness. Her physicians thought it best to have the patient join her husband at the earliest possible moment. She was thought well enough to travel alone with the baby. Unexpectedly, during the trip she had to change plans. This stumped her completely. She just sat down with her baby in the waiting room at the airport, quite lost and not able to ask for information nor to make arrangements for herself. She did not improve much after she had joined her husband. In going shopping, for in- stance, she would stand before the grocery shelves, unable to think of things to buy. The patient was very alarmed and depressed about her condition. In the hospital she kept repeating her complaints over and over, and said she feared she was going crazy and that she could not be helped.
The husband reported that the patient had changed in other respects too. Whereas she had been sexually rather frigid before the delivery, she all of a sudden became very passionate.
flospitalization and psychotherapy seemed to do little good. So the patient was discharged and brought in by her husband at intervals for electric shock treatments. After very few treatments the patient felt normal and both she and her husband felt that she was now less inhibited, warmer, and able to enjoy herself more.
At the present time the psychological meanings and effects of shock treat- ments are not sufficiently understood to permit theorizing concerning its role in this case. Its evaluation is rendered the more difficult by the fact that the patient had received and was receiving psychotherapy. The doctors' and husband's acceptance of her newly awakened sensuality may have helped
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the patient to accept this part ofherself, and this may have been an important factor in her improvement.
Another case of the same general type was a 24-year-old mother of two children. She too had an episode of depersonalization and forgetfulness fol- lowing the birth of the first child. This woman could have been taken for a naive high school girl. Her usual submissive and conventional "good girl" be- havior occasionally alternated with outbursts of anger and spite. She was a very dependent person with no ideas and opinions of her own and without interests outside of the domestic sphere. When her husband's support was withdrawn (because of illness) just after she had her second child, she suf- fered a paranoid schizophrenic episode, became afraid someone would harm her and the children, that her husband or relatives would take one of her daughters out and not bring her back.
Still another case was that of a girl who had always been a particularly con- scientious worker and who was completely submissive to her rigid, unsym- pathetic parents and aggressive older sister, without ever becoming aware of any resentment. When this girl was promoted to a job of considerable re- sponsibility she developed extreme headaches and entered a state of depres- sion and anxiety, in which she accused herself of being bad, thought people were looking at her, and feared she would lose her mind.
This girl and several other high-scoring women suffered, during the acute stages of their illness, from a mood disturbance which could only be de- scribed as "agitated depression. " (In some cases this was accompanied by suicidal ideas. ) These depressions, however, were different from those seen in the patients who were subject to periodic neurotic depressions. They were often accompanied by somewhat bizarre ideas and in general showed schizoid qualities. For this reason they were sometimes labeled schizo-affective reactions.
Few of these cases had the slightest idea of or interest in current issues and were very unsure of the few ideas they could voice during the interviews. Their ideologies about outgroups were meager, less elaborated, and even more naive and stereotyped than those of less disturbed high-scoring subjects. Their rejection of outgroups-in the abstract at least-was extremely strong, leading to very high prejudice scores and often to emotionally charged re- sponses during interviews such as "You wouldn't want to have a black baby, would you? " This is an expression of their particular ego weakness, necessitat- ing special efforts at creating and maintaining countercathexes.
2. THE LOW SCORERS
The pattern formed by the symptoms in List B of Category VII is dif- ferent. The unacceptable impulses-although not all conscious nor undis- guised-are more ego-assimilated and are perceived as part of the self. The
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low-scoring patients generally came to the Clinic with a particular psycho- logical problem they wanted to solve. They complained of certain conflicts or anxieties about some more or less definite idea or situation or were consciously dissatisfied with their sex role. Many of these are character neuroses. The "evil" was not sought outside but in the self. Elsewhere in the present volume it has been shown that high scorers on E are typically extrapunitive, while low scorers are intrapunitive. Intrapunitiveness has been understood as a sign of a strict but internalized superego and probably also of a somewhat masochistic character structure. The psychologically ill low scorers seem to show this tendency in exaggerated form: in (neurotic) depression, suicidal ideas, inferiority, and guilt feelings.
Their greater acceptance of their instinctual and fantasy lives and their relative independence from conventional restrictions give great variety, in- dividuality, and even bizarreness to the pathological ideas and behavior of these patients.
In some ways many of these patients (although by no means all of them) behaved in a way that is opposite to the cultural norm for their sex. Some of the men were shy, timid, passive, and dependent and had some interests more often found in women. Some of the women were aggressive, less inter- ested in home and family than in some occupational achievement. Homo- sexuality and sexual perversions were more freely admitted, and conflicts about such impulses were often quite conscious and undisguised. (This does not mean that the low scorers have more homosexual tendencies. There are probably just as many if not many more high scorers with such impulses. But in the latter case, these impulses and fantasies are strongly disguised and re- pressed. )
a. Low-scoRING MEN. The low scorers on E presented such a variety of complaints and clinical pictures that it is almost impossible to fit them into a few "types. " While some had psychoses or classical neuroses with anxiety- hysterical and compulsive symptoms, many cases presented character dis- orders which had come to the fore or were accentuated because of situational factors. An example of this type was a very dependent man, married to a more aggressive woman to whom he was very much attached and. sexually attracted. The relationship, always problematic, had become intolerable since the wife had a second child whom she rejected. The Clinic suggested foster-home placement for the child. The patient could not accept this nor could he decide to leave his famliy.
Broadly speaking, the low-scoring men were generally unaggressive, nur- turant, often somewhat withdrawn and inhibited socially. They came to the Clinic with depressions and conscious anxieties relating to problems of sex, work, or general adjustment. In contrast to the high-scoring men, the prob- lems as stated by these patients referred directly to their relationships to others. During the war a few of them suffered acute conflict about the prob-
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lem of participation, leading, in'a few cases, to self-inflicted injuries to avoid the draft, in others to conscientious objection. This was not primarily because of fear of physical injury or death but because of ideological reasons and a horror of being forced to kill.
An illustrative case is that of a young man of college age who had been in a camp for conscientious objectors. He was short and slight. His manner and speech betrayed much tension and self-consciousness. He was very unsure of himself and suffered somewhat from compulsive doubt and indecision. He had well-formed opinions about some subjects-such as the problems of minorities and pacifism-but in most areas he was quite uncertain, mentioning one opinion and then retreating when challenged by the interviewer, saying "I really don't know much about it yet-I have to read a lot more. " He was
keenly interested in politics and concerned about social progress. He realized that his occupational choice-to counsel people about their personal problems -stemmed from awareness of his own inner struggles and from his own desire to be helped.
The patient voluntarily sought help because of restlessness, anxiety, occa- sional depression, and inability to concentrate. He also had severe feelings of inadequacy, stage-fright, social anxiety, and several fears-of the dark, of physical injury, and of graveyards and mental institutions.
The patient's father was of lower-class origin with a grade-school educa- tion, who became a carpenter, then a farmer and minister in a fundamentalist church. He was a stern, dominating and punitive man with narrow, funda- mentalist and puritanical ideas, who made the children work hard on the farm and dealt out severe corporal punishment.
