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? . PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 937
There was a significant relationship between variable I and ethnocentrism. According to rater A, 66 per cent of the high scorers emphasized their physical complaints, whereas about 79 per cent of the low scorers failed to do so. The control rater's figures are lower: 55 per cent for the high scorers, 73 per cent for the low scorers. In addition, case studies indicated that this variable is important for differentiating subjects high and low on E.
To be sure, there were some cases of low scorers with tendencies toward conversion symptoms or other psychogenic somatic disturbances. But such symptoms, together with marked anxious concern about bodily integrity was characteristic of high scorers. This anxiety is often extended to the function- ing of the nervous system or "mind. " Thus, high-scoring patients complain and have anxious concern about headaches, various sensory disturbances, loss of memory, nervousness, and "going crazy. " There is also a tendency on the part of the high scorers to develop somatic rather than psychological symptoms. Many of these somatic symptoms, on closer examination, turn out to be expressions of repressed affects. Thus, the tendency to develop and to focus on somatic complaints can be considered part of the defensive activity of the high scorer's narrow ego, which shuts out extensive parts of the in- dividual's inner life and, as an additional defensive measure, causes rejection of any thinking in psychological terms and, instead, an emphasis on thinking in terms of physical causation. Thus, variable I may be an expression of the same processes which underlie variable II, and, in a sense, all the other variables as well.
Variable II: lntraception. This variable had the highest reliability with raters A and B (83 per cent). Among the agreements of A with the control raters, this variable ranked only sixth (72 per cent). As noted above, a differ- ence in training between raters A and B on the one hand and the control rater on the other is probably the cause of the difference in the reliabilities of the two sets of ratings. The fact that A's and B's ratings agreed more closely with E score (83 per cent) than did those of the control rater (65 per cent) is probably to be explained in the same way.
From these data it appears that (r) adequately trained raters can arrive at very reliable ratings of intraception, using patients' statements about their complaints in a first psychiatric interview; (2) intraception is highly corre- lated with lack of ethnocentrism. The latter proposition is supported by a great deal of evidence from other material presented in this volume, in con- nection with the F scale, the Projective Questions, and particularly the Thematic Apperception Test and the interviews.
In the Clinic the difference between high and low scorers on intraception became very clear when any kind of psychotherapy was attempted. Some of the high-scoring subjects whom we interviewed were almost unable to accept the notion of psychological causation of their disturbances, and it took a great deal of time to make them see some very obvious connections
? THE AUTHORITARIAN PERSONALITY
between their symptoms, on the one hand, and some anxiety-producing factors in their life situation and events in the past, on the other. The low scorers either knew these more obvious connections before coming to the Clinic (often reporting about their inner and outer lives with a great deal of awareness of their own and other's psychological processes) or were quick in grasping the therapist's interpretations. Many of these latter patients, at least at first sight, appear to be especially good subjects for psychotherapy. They are cooperative, perceptive, and give excellent histories. But often it is difficult to effect changes in their symptoms because of their characteristic defenses: isolation of affect and intellectualization. It is as if they "can afford" to know more about their inner lives because, among other things, their egos, used to admitting impulses, have developed certain intellectual ways of dealing with drives and emotions.
Variable Ill: Ego-alienness. This variable had the lowest reliabilities. The agreement between A and the control rater was only 65 per cent; the agreement between A and B was 70 per cent. The control rater, as noted above, was quite unsure of her ratings and expressed misgivings about the way in which the variable had been defined. Indeed, it seems likely that the breadth of the category and the absence from it of behavioral criteria lowered the reliability of both sets of ratings. Thus it happened that the control rater tried mainly to judge ego-alienness from the degree of conscious acceptance or rejection of the symptoms as revealed by the interview. Raters A and B also included in their judgments the nature of the symptoms themselves, regardless of the patient's expressed attitude toward them. Thus they judged the presence of predominantly psychosomatic symptoms, or of vague anxiety without content, as more ego-alien than conscious conflicts or feelings of failure.
As was to be expected, the control rater's judgment did not agree very? well with E score (56 per cent). Rater A's ratings, however, showed a fairly high relationship (77 per cent). Examination of the data revealed that some of the low-scoring patients, who on the basis of this variable were judged to be ethnocentric, showed psychotic manifestations. Such manifestations actually have much more ego-alien quality than the neurotic symptoms which generally predominated in our group. The variable probably works better for the high- than for the low-scoring group. ?
Variable IV: Externalized Theory of Onset and Causes of the Ill- ness. The reliabilities here are quite good-74 per cent for A and the control rater, and 76 per cent for A and B. Rater A's agreement with E is her lowest
(67 per cent); the control rater agreed more highly withE (71 per cent). In general, the variable seemed to work better for the high scorers. It is possible that this has to do with the fact that more "neutrals" were scored for this category than for any other, and there were a few more "neutrals" in the low-scoring group. The large number of neutral ratings seemed to be
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 939
due to the circumstance that . not all subjects talked about (or were even asked about) the onset of their illness in this interview but confined them- selves to describing their present difficulties. The high scorers more often brought up the onset and causes of their symptoms because they felt as if these symptoms had come about mysteriously "all of a sudden" on a certain day and that "everything had been quite all right before. "
This is another example of the high scorers' unfamiliarity with their inner lives, their need to be like everyone else, and their strenuous efforts at keep- ing less acceptable impulses and emotions completely out of consciousness. When these impulses finally do break through in the form of symptoms, they are felt as ego-alien intruders, which appear "suddenly" and often "without any reason at all. "
Variable V: Spontaneous Mention of Unhappy Childhood or Unhappy Family Relationships. The least ambiguous category, and therefore the one receiving the highest agreement scores (91 per cent and 95 per cent) is variable V. Here the rater simply had to state whether the patient spon- taneously mentioned unhappy childhood or family relationships. 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
? THE AUTHORITARIAN PERSONALITY
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,
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 941
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 ?
? 942 THE AUTHORIT ARIAN PERSONALITY
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
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 943
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.
? 944
THE AUTHORITARIAN PERSONALITY
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
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 945
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
? THE AUTHORITARIAN PERSONALITY
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.
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 947
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.
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? . PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 937
There was a significant relationship between variable I and ethnocentrism. According to rater A, 66 per cent of the high scorers emphasized their physical complaints, whereas about 79 per cent of the low scorers failed to do so. The control rater's figures are lower: 55 per cent for the high scorers, 73 per cent for the low scorers. In addition, case studies indicated that this variable is important for differentiating subjects high and low on E.
To be sure, there were some cases of low scorers with tendencies toward conversion symptoms or other psychogenic somatic disturbances. But such symptoms, together with marked anxious concern about bodily integrity was characteristic of high scorers. This anxiety is often extended to the function- ing of the nervous system or "mind. " Thus, high-scoring patients complain and have anxious concern about headaches, various sensory disturbances, loss of memory, nervousness, and "going crazy. " There is also a tendency on the part of the high scorers to develop somatic rather than psychological symptoms. Many of these somatic symptoms, on closer examination, turn out to be expressions of repressed affects. Thus, the tendency to develop and to focus on somatic complaints can be considered part of the defensive activity of the high scorer's narrow ego, which shuts out extensive parts of the in- dividual's inner life and, as an additional defensive measure, causes rejection of any thinking in psychological terms and, instead, an emphasis on thinking in terms of physical causation. Thus, variable I may be an expression of the same processes which underlie variable II, and, in a sense, all the other variables as well.
Variable II: lntraception. This variable had the highest reliability with raters A and B (83 per cent). Among the agreements of A with the control raters, this variable ranked only sixth (72 per cent). As noted above, a differ- ence in training between raters A and B on the one hand and the control rater on the other is probably the cause of the difference in the reliabilities of the two sets of ratings. The fact that A's and B's ratings agreed more closely with E score (83 per cent) than did those of the control rater (65 per cent) is probably to be explained in the same way.
From these data it appears that (r) adequately trained raters can arrive at very reliable ratings of intraception, using patients' statements about their complaints in a first psychiatric interview; (2) intraception is highly corre- lated with lack of ethnocentrism. The latter proposition is supported by a great deal of evidence from other material presented in this volume, in con- nection with the F scale, the Projective Questions, and particularly the Thematic Apperception Test and the interviews.
In the Clinic the difference between high and low scorers on intraception became very clear when any kind of psychotherapy was attempted. Some of the high-scoring subjects whom we interviewed were almost unable to accept the notion of psychological causation of their disturbances, and it took a great deal of time to make them see some very obvious connections
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between their symptoms, on the one hand, and some anxiety-producing factors in their life situation and events in the past, on the other. The low scorers either knew these more obvious connections before coming to the Clinic (often reporting about their inner and outer lives with a great deal of awareness of their own and other's psychological processes) or were quick in grasping the therapist's interpretations. Many of these latter patients, at least at first sight, appear to be especially good subjects for psychotherapy. They are cooperative, perceptive, and give excellent histories. But often it is difficult to effect changes in their symptoms because of their characteristic defenses: isolation of affect and intellectualization. It is as if they "can afford" to know more about their inner lives because, among other things, their egos, used to admitting impulses, have developed certain intellectual ways of dealing with drives and emotions.
Variable Ill: Ego-alienness. This variable had the lowest reliabilities. The agreement between A and the control rater was only 65 per cent; the agreement between A and B was 70 per cent. The control rater, as noted above, was quite unsure of her ratings and expressed misgivings about the way in which the variable had been defined. Indeed, it seems likely that the breadth of the category and the absence from it of behavioral criteria lowered the reliability of both sets of ratings. Thus it happened that the control rater tried mainly to judge ego-alienness from the degree of conscious acceptance or rejection of the symptoms as revealed by the interview. Raters A and B also included in their judgments the nature of the symptoms themselves, regardless of the patient's expressed attitude toward them. Thus they judged the presence of predominantly psychosomatic symptoms, or of vague anxiety without content, as more ego-alien than conscious conflicts or feelings of failure.
As was to be expected, the control rater's judgment did not agree very? well with E score (56 per cent). Rater A's ratings, however, showed a fairly high relationship (77 per cent). Examination of the data revealed that some of the low-scoring patients, who on the basis of this variable were judged to be ethnocentric, showed psychotic manifestations. Such manifestations actually have much more ego-alien quality than the neurotic symptoms which generally predominated in our group. The variable probably works better for the high- than for the low-scoring group. ?
Variable IV: Externalized Theory of Onset and Causes of the Ill- ness. The reliabilities here are quite good-74 per cent for A and the control rater, and 76 per cent for A and B. Rater A's agreement with E is her lowest
(67 per cent); the control rater agreed more highly withE (71 per cent). In general, the variable seemed to work better for the high scorers. It is possible that this has to do with the fact that more "neutrals" were scored for this category than for any other, and there were a few more "neutrals" in the low-scoring group. The large number of neutral ratings seemed to be
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due to the circumstance that . not all subjects talked about (or were even asked about) the onset of their illness in this interview but confined them- selves to describing their present difficulties. The high scorers more often brought up the onset and causes of their symptoms because they felt as if these symptoms had come about mysteriously "all of a sudden" on a certain day and that "everything had been quite all right before. "
This is another example of the high scorers' unfamiliarity with their inner lives, their need to be like everyone else, and their strenuous efforts at keep- ing less acceptable impulses and emotions completely out of consciousness. When these impulses finally do break through in the form of symptoms, they are felt as ego-alien intruders, which appear "suddenly" and often "without any reason at all. "
Variable V: Spontaneous Mention of Unhappy Childhood or Unhappy Family Relationships. The least ambiguous category, and therefore the one receiving the highest agreement scores (91 per cent and 95 per cent) is variable V. Here the rater simply had to state whether the patient spon- taneously mentioned unhappy childhood or family relationships. 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.
