Contributions toward medical psychology: Theory and psychodiagnostic methods Vol 1.

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Contributions toward medical psychology: Theory and psychodiagnostic methods Vol 1.

Table of contents :
Contributions Toward Medical Psychology......Page 1
Foreword......Page 5
Acknowledgments......Page 9
Illustrations......Page 19
Tables......Page 25
Chapter 1 The Profession Of Psychology As Seen By A Doctor Of Medicine1......Page 29
Part I Psychology And Medicine......Page 27
Chapter 2 The Psychological Aspects Of Medicine......Page 38
Chapter 3 Theoretical Schools Of Psychology......Page 57
Chapter 4 Human Infancy And The Embryology Of Behavior......Page 77
Chapter 5 Needs And Drives Of Organisms......Page 109
Chapter 6 Determinants And Components Of Personality......Page 139
Chapter 7 What Is Normal Behavior?......Page 170
Chapter 8 Concept Of A Psychosomatic Affection......Page 205
Chapter 9 Guide To Interviewing And Clinical Personality Study......Page 219
Chapter 10 Technique Of Interviewing A Patient With Psychosomatic Disorder......Page 257
Chapter 11 The General-adaptation-syndrome In Its Relationships To Neurology, Psychology, And Psychopathology......Page 266
Chapter 12 Psychosomatic Aspects Of Childhood......Page 309
Chapter 13 Life Situations, Emotions, And Gastric Function: A Summary......Page 324
Chapter 14 Life Stress And Bodily Disease1......Page 353
Chapter 15 The Concept Of Culture And The Psychosomatic Approach......Page 408
Chapter 16 Personality And Chronic Illness......Page 438
Chapter 17 Psychosurgery......Page 450
Chapter 18 Rehabilitation And Convalescence: The Third Phase Of Medical Care......Page 478

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CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY Contributors FRANZ ALEXANDER, M.D.

MARGARET MEAD, PH.D.

ROBERT B. AMMONS, PH.D.

MAUD A. MERRILL, PH.D.

HARRIET BABCOCK, PH.D.

O. HOBART MOWRER, PH.D.

SAMUEL J . BECK, PH.D.

RUTH L. MUNROE, PH.D.

JOHN E. BELL, ED.D.

HENRY A. MURRAY, M.D., PH.D.

KARL M . BOWMAN, M.D.

PAUL G. MYERSON, M.D.

KEEVE BRODMAN, M.D.

JANET E. RAFFERTY, M.A.

JOHN N . BUCK

SAUL ROSENZWEIG, PH.D.

PSYCHE CATTELL, ED.D.

JULIAN B. ROTTER, PH.D.

STANLEY COBB, M.D.

JURGEN RUESCH, M.D.

EDGAR A. DOLL, PH.D.

HOWARD A. RUSK, M.D.

JON EISENSON, PH.D.

ROY SCHAFER, PH.D.

ALBERT ELLIS, PH.D.

MARTIN SCHEERER, PH.D.

ARNOLD GESELL, M.D., PH.D.

HANS SELYE, M.D., PH.D.

KURT GOLDSTEIN, M.D.

WALTER C. SHIPLEY, PH.D.

HARRISON G. GOUGH, PH.D.

EDWARD L. SIEGEL, PH.D.

MILTON GREENBLATT, M.D.

LESTER W. SONTAG, M.D.

ALAN GREGG, M.D.

JOHN M . STALNAKER, M.A.

JAMES L. HALLIDAY, M.D.

EDWARD K. STRONG, JR., PH.D.

EUGENIA HANFMANN, PH.D.

LEWIS M . TERMAN, PH.D.

MOLLY R. HARROWER, PH.D.

FRANCIS ORALIND TRIGGS, PH.D.

HOWARD F. HUNT, PH.D.

ROBERT I. WATSON, PH.D.

MAX L. HUTT, PH.D.

DAVID WECHSLER, PH.D.

JOSEPH JASTAK, PH.D.

ARTHUR WEIDER, PH.D.

SAMUEL KELLMAN, M.A.

JOHN C. WHITEHORN, M.D.

CLYDE KLUCKHOHN, PH.D.

STEWART WOLF, M.D.

HAROLD G.

WOLFF, M.D.

CONTRIBUTIONS TOWARD

MEDICAL PSYCHOLOGY Theory and Psychodiagnostic Methods

Edited by

ARTHUR WEIDER, Ph.D. ASSOCIATE PROFESSOR OF MEDICAL PSYCHOLOGY DEPARTMENT OF PSYCHIATRY AND MENTAL HYGIENE UNIVERSITY OF LOUISVILLE SCHOOL OF MEDICINE

WITH A FOREWORD BY

DAVID WECHSLER, PhD. ASSOCIATE CLINICAL PROFESSOR OF MEDICAL PSYCHOLOGY NEW YORK UNIVERSITY COLLEGE OF MEDICINE CHIEF PSYCHOLOGIST, BELLEVUE PSYCHIATRIC HOSPITAL

VOLUME I

THE RONALD PRESS COMPANY 1 N E W YORK

Copyright, 1953, by T H E RONALD PRESS COMPANY

All Rights Reserved The text of this publication or any part thereof may not be reproduced in any manner whatsoever without permission in writing from the publisher.

Library of Congress Catalog Card Number: 52-11112 PRINTED IN THE UNITED STATES OF AMERICA

To my father, whose memory has been a constant source of inspiration, this work is respectfully dedicated

FOREWORD Medical psychology as an applied art, that is, the art of interpreting mental reactions of the ill in relation to their physical symptoms, is as old as medicine itself. As a specialized discipline, or even a specialized area of medicine, however, it is only of recent affirmation and its full scope still remains to be defined. Historically, medical psychology was identified with mind healing, and this meaning, reflected in the derivation of the word psychiatry itself, is still encountered in the literature. Actually, medical psychology includes much more, and is no longer linked exclusively to any particular branch of medicine, including psychiatry. Broadly speaking, medical psychology concerns itself with the interrelations between mind and body in so far as these interrelationships have to do with the physical and mental health of the individual. In practice, it is concerned with more concrete problems such as the effect of emotions on gastric functions, techniques of interviewing patients, mental changes following psychosurgery as revealed by psychometric tests, etc. The possibility of dealing effectively with such problems obviously depends upon work already done in basic sciences and calls for contributions, as the contents of these volumes show, which cut across a number of scientific disciplines. It is difficult to predict which of the basic sciences or even which of the applied sciences will be most called upon in the future development of medical psychology. Many approaches will be involved, although it seems probable that, for answers to basic questions, medical psychology will have to turn most often to physiology and experimental psychology and for practical applications to internal medicine, psychiatry, and clinical psychology. But here, as elsewhere, practical applications will have to await the contributions of basic research. The material in the present volumes shows broadly what has been done in the field thus far and gives some indication as to the direction which the budding science of medical psychology is taking. It is perhaps a little weighted on the side of psychometric techniques and test evaluation, but as these represent an area in which widest development has taken place in the past ten years, more detailed discussion of these contributions would seem justified. Altogether, the reader will find that Dr. Weider has made an excellent selection. DAVID WECHSLER

PREFACE The purpose of this work is to present a balanced group of significant professional contributions by outstanding authorities in the field of medical psychology. This modern scientific approach to the study of health and disease, drawing upon psychiatry, clinical psychology, psychosomatic medicine, and other professional disciplines, has enlisted the efforts of scores of physicians, psychologists, anthropologists, and other students of human behavior. The editor's task has been to select and arrange the most pertinent, representative, and comprehensible statements from the current writing and published work of these authorities. These volumes are designed for use by physicians, interns and residents, nurses, hospital technicians, psychologists, psychiatric social workers, psychotherapists in general, and other students of human behavior. They can also be used in advanced college and postgraduate courses in medical and clinical psychology, psychiatry, and general medicine. The first three parts, comprising Volume I, are devoted mainly to general concepts of the role of psychology in medicine. As a guide in selecting authors and topics for these parts of the book, the editor has drawn upon surveys made in preparing course material for medical students, interns, residents, nurses, and social workers. The contributors to Part IV, which constitutes Volume II, are leading specialists in the nature and use of the more important psychodiagnostic tests and methods. The collection is thus the result of a whole-hearted collaboration of many writers, all alike aiming at a more integrated approach to the problems of human behavior in health and in disease. The editor wishes to extend his personal thanks to them, individually and collectively, for making this volume possible. The editor is grateful for the assistance, guidance, and suggestions he received from his colleagues in the Department of Psychiatry and Mental Hygiene of the University of Louisville School of Medicine. Special thanks are expressed to Dr. S. Spafford Ackerly, Chairman of the Department, whose helpful criticisms were always tendered with sincere kindness and thoughtful consideration. The editor also wishes to acknowledge the encouragement of Dr. John J. Head, and the cooperation of Adrienne Yanekian, in helping with the reading vii

viii

PREFACE

of proofs, and of Miriam Hollis and Doris Raymer in giving secretarial assistance. The influence of many former colleagues escapes the scrutiny of specific acknowledgment but is nonetheless deeply appreciated. Lastly, I wish to acknowledge heartfelt appreciation for inestimable devotion and encouragement from one known simply as Sissie. ARTHUR WEIDER

ACKNOWLEDGMENTS The editor wishes to acknowledge the cooperation of the authors, associations, and publishers listed below for their permission to publish copyrighted materials: Acta, Inc., Medical Publishers of Montreal,, Canada, for permission to reprint from Stress, a monograph by Dr. Hans Selye which appeared in 1950, the chapter entitled "The General-Adaptation-Syndrome in Its Relationships to Neurology, Psychology, and Psychopathology," pages 656-79. The American Anthropological Association, for the article by Dr. Clyde Kluckhohn and Dr. O. Hobart Mowrer entitled "The Determinants of Personality Formation," which appeared in the American Anthropologist for 1944, Volume XLVI, pages 1-29. The American Medical Association, for the article by Dr. John C. Whitehorn entitled "Guide to Interviewing and Clinical Personality Study," which appeared in Archives of Neurology and Psychiatry for September, 1944, Volume LII, pages 197-216; for the article by Dr. Jurgen Ruesch and Dr. Karl M. Bowman entitled "Personality and Chronic Illness," which appeared in the Journal of the American Medical Association for March 27, 1948, Volume CXXXVI, pages 851-55; and for the article by Dr. Howard A. Rusk entitled "Rehabilitation and Convalescence : The Third Phase of Medical Care," which appeared in the Journal of the American Medical Association for May 21, 1949, Volume CXL, pages 286-92. The American Psychological Association, for the article by Dr. Alan Gregg entitled "The Profession of Psychology as Seen by a Doctor of Medicine," which appeared in the American Psychologist for September, 1948, Volume III, pages 397-401. The American Psychosomatic Society and W. W. Norton and Company, Inc., for the article by Dr. Franz Alexander entitled "The Psychological Aspects of Medicine," which appeared in Psychosomatic Medicine for January 1939, Volume I, pages 7-18, and also in Dr. Alexander's book, Psychosomatic Medicine: Its Principles and Applications (New York: W. W. Norton and Company, Inc., 1950). Dr. T. F. Fox, for the article by Dr. James L. Halliday entitled "Concept of a Psychosomatic Affection," which appeared in The Lancet for December 4, 1943, Volume CCXLV, pages 692-96. ix

x

ACKNOWLEDGMENTS

J. B. Lippincott Company, for the article by Dr. Stewart Wolf and Dr. Harold G. Wolff entitled "Life Situations, Emotions, and Gastric Function: A Summary," which appeared in the American Practitioner for September, 1948, Volume III, pages 1-14. The Massachusetts Medical Society, for the article by Dr. Milton Greenblatt and Dr. Paul G. Myerson entitled "Psychosurgery," which appeared in the New England Journal of Medicine for June 23, 1949, Volume CCXL, pages 1006-17. The Ronald Press Company, for the chapter by Dr. O. Hobart Mowrer entitled "What Is Normal Behavior?" which appeared in An Introduction to Clinical Psychology, edited by Dr. L. A. Pennington and Dr. Irwin A. Berg, copyright 1948, The Ronald Press Company, pages 17-46. W. B. Saunders Company, for the article by Dr. Stanley Cobb entitled "Technique of Interviewing a Patient with Psychosomatic Disorder," which appeared in the Medical Clinics of North America for September, 1944, Volume XXVIII, pages 1210-16, and is reprinted with the permission of the author and the publishers. The Society for Projective Techniques and Rorschach Institute, Inc., and Dr. Mortimer M. Meyer for permission to Dr. John E. Bell and Dr. Edward L. Siegel to publish in abridged form "Psychodiagnostic Methods at Work: A Case Study," which appeared in the Journal of Projective Techniques for 1949, Volume XIII, pages 155-209 and 433-68; and to the following who contributed to this case study: Irving Frank, Max L. Hutt, Bruno Klopfer, Karen Machover, Roy Schafer, Morris Stein, and Frederick Wyatt. The William Alanson White Psychiatric Foundation, for the article by Dr. Margaret Mead entitled "The Concept of Culture and the Psychosomatic Approach," which appeared in Psychiatry for 1947, Volume X, pages 57-76. The Williams and Wilkins Company, for permitting the publication in modified form of Dr. Harold G. Wolff's chapter "Life Stress and Bodily Disease," which appeared in the 1949 Proceedings of the Association for Research in Nervous and Mental Diseases. Yale University Press, for the article by Dr. Arnold Gesell entitled "Human Infancy and the Embryology of Behavior," which appeared in the American Scientist for October, 1949, Volume XXXVII, Number 4, pages 529-53. The kind cooperation of Dr. George A. Baitsell, editor of Science in Progress, Seventh Series, is also acknowledged, since Dr, Gesell's article is also included in the latter publication.

VOLUME I PART I

Psychology and Medicine CHAPTER

1

PAGE

T H E PROFESSION OF PSYCHOLOGY AS S E E N BY A DOCTOR OF M E D I C I N E . . . . . . . . .

3

By ALAN GREGG, M.D., Vice-President, The Rockefeller Foundation 2

T H E PSYCHOLOGICAL ASPECTS OF M E D I C I N E .

.

12

By FRANZ ALEXANDER, M.D., Director, the Institute for

Psychoanalysis, Chicago; Clinical Professor of Psychiatry, University of Illinois PART II

Some Aspects of Psychology 3

THEORETICAL SCHOOLS OF PSYCHOLOGY

31

By ALBERT ELLIS, Ph.D., Consulting Psychologist, New York City; Formerly Chief Psychologist, New Jersey Department of Institutions and Agencies 4

H U M A N I N F A N C Y AND T H E EMBRYOLOGY OF BEHAVIOR .

51

By ARNOLD GESELL, Ph.D., M.D., Director Emeritus of the former Clinic of Child Development, Yale University School of Medicine; Research Consultant, Gesell Institute of Child Development, New Haven, Connecticut 5

NEEDS AND DRIVES OF ORGANISMS

.

.

.

. 7 ?

By ROBERT B. AMMONS. Ph.D., Assistant Professor of Psychology, University of Louisville 6

D E T E R M I N A N T S AND COMPONENTS OF PERSONALITY

By CLYDE KLUCKHOIIN, Ph.D., Director, Russian Research Center, Harvard University; and 0. HOBART MOWRER, Ph.D., Research Professor of Psychology, University of Illinois xi

105

xii

CONTENTS

CHAPTER

7

PAGE

W H A T I S NORMAL BEHAVIOR?

136

By O. HOBART MOWRER, Ph.D., Research Professor of Psychology, University of Illinois PART III

Psychosomatic Relationships 8

CONCEPT OF A PSYCHOSOMATIC A F F E C T I O N .

.

.

.

173

By JAMES L. HALLIDAY, M.D., Regional Medical Officer, Department of Health for Scotland 9

GUIDE TO INTERVIEWING AND CLINICAL STUDY

PERSONALITY

.

187

By JOHN C. WHITEHORN, M.D., Henry Phipps Professor and Director of the Department of Psychiatry, School of Medicine, Johns Hopkins University; Psychiatrist-in-Chief, Johns Hopkins Hospital 10

T E C H N I Q U E OF INTERVIEWING A P A T I E N T W I T H P S Y CHOSOMATIC DISORDER

.

225

By STANLEY COBB, M.D., Bullard Professor of Neuropathology, Harvard Medical School; Psychiatrist-in-Chief, Massachusetts General Hospital 11

T H E GENERAL-ADAPTATION-SYNDROME

I N ITS R E L A -

TIONSHIPS TO NEUROLOGY, PSYCHOLOGY, AND PSYCHOPATHOLOGY

234

By HANS SELYE, M.D., Ph.D., Professor and Director of

the Institute of Experimental Medicine and Surgery, Universite de Montreal 12

PSYCHOSOMATIC ASPECTS OF CHILDHOOD

.

.

.

.

275

By LESTER W. SONTAG, M.D., Director, Fels Research Institute for the Study of Human Development, Antioch College; Fellow, Department of Psychiatry, University of Cincinnati Medical School 13

L I F E SITUATIONS, EMOTIONS, AND GASTRIC F U N C T I O N : A SUMMARY

By STEWART WOLF, M.D., Professor and Head of the Department of Medicine, University of Oklahoma School of Medicine; and HAROLD G. WOLFF, M.D., Professor of Medi-

290

CONTENTS

xiii

CHAPTER

PAGE

cine (Neurology) and Associate Professor of Psychiatry, Cornell University Medical College 14

L I F E STRESS AND BODILY DISEASE

315

By HAROLD G. WOLFF, M.D., Professor of Medicine (Neu-

rology) and Associate Professor of Psychiatry, Cornell University Medical College 15

T H E CONCEPT OF CULTURE AND T H E PSYCHOSOMATIC APPROACH

368

By MARGARET MEAD, Ph.D., Associate Curator of Ethnology, American Museum of Natural History 16

PERSONALITY AND CHRONIC ILLNESS

398

By JURGEN RuESCH. M.D., Associate Professor of Psychiatry, University of California School of Medicine; Research Psychiatrist, Langley Porter Clinic; and KARL M. BOWMAN, M.D., Professor of Psychiatry, University of California School of Medicine ; Medical Superintendent, Langley Porter Clinic 17

PSYCHOSURGERY

410

By MILTON GREENBLATT, M.D., Clinical Associate in Psy-

chiatry, Harvard Medical School; Chief of Laboratories and Research, Boston Psychopathic Hospital; and PAUL G. MVERSON, M.D., Assistant Professor of Psychiatry, Tufts College Medical School; Physician in Charge, Department of Nervous & Mental Diseases, Boston Dispensary 18

REHABILITATION

AND CONVALESCENCE:

THE

THIRD

P H A S E OF MEDICAL CARE

By HOWARD A. RUSK, M.D., Professor and Chairman of the

Department of Physical Medicine and Rehabilitation, New York University College of Medicine

438

VOLUME II PART IV

Psychodiagnostic Methods and Medical Practice CHAPTER 19

PAGE

C O N C E P T S OF P S Y C H O D I A G N O S T I C T E S T S

459

By ARTHUR WEIDER, Ph.D., Associate Professor of Medical Psychology, Department of Psychiatry and Mental Hygiene, University of Louisville School of Medicine 20

DEVELOPMENTAL A.

PROCEDURES

GESELL D E V E L O P M E N T A L S C H E D U L E S

.

.

.

.

485

By ARNOLD GESELL, M.D., Ph.D., Director Emeritus of the former Clinic of Child Development, Yale University School of Medicine; Research Consultant, Gesell Institute of Child Development, New Haven, Connecticut B. VINELAND SOCIAL MATURITY SCALE . . . . By EDGAR A. DOLL, Ph.D., Director of Research, Psychology and Education, Devereux Schools, Devon, Pennsylvania; Formerly Director of Research, Vineland Training School, Vineland, New Jersey 21

495

T E S T S OF I N T E L L I G E N C E A.

I N F A N T I N T E L L I G E N C E SCALE

507

By PSYCHE CATTELL, Ed.D., Psychologist, Lancaster Guidance Clinic, Lancaster, Pennsylvania B. 1937 STANFORD-BINET SCALES By LEWIS M. TERMAN, Ph.D., Emeritus Professor of Psychology, Stanford University; and MAUD A. MERRILL, Ph.D., Professor of Psychology, Stanford University

510

C. WECHSLER INTELLIGENCE SCALE FOR CHILDREN . By DAVID WECHSLER, Ph.D., Associate Clinical Professor of Medical Psychology, New York University, College of Medicine; Adjunct Professor of Psychology, Graduate School of Arts and Sciences, New York University ; Chief Psychologist, Bellevue Psychiatric Hospital;

522

CONTENTS

xv

CHAPTER

PAGE

and ARTHUR WEIDER, Ph.D., Associate Professor of Medical Psychology, Department of Psychiatry and Mental Hygiene, University of Louisville School of Medicine D.

WECHSLER-BELLEVUE INTELLIGENCE ADOLESCENTS AND ADULTS

SCALE FOR 530

By ROBERT I. WATSON, Ph.D., Associate Professor of Medical Psychology, Department of Neuropsychiatry, and Assistant Dean, Washington University School of Medicine 22

TESTS OF PERSONALITY : QUESTIONNAIRES A.

MINNESOTA

MULTIPHASIC

PERSONALITY

INVEN-

TORY

545

By HARRISON G. GOUGH, Ph.D., Assistant Professor of Psychology, and Research Associate, Institute of Personality Assessment and Research, University of California, Berkeley, California B.

CORNELL MEDICAL INDEX-HEALTH QUESTIONNAIRE

568

By KEEVE BRODMAN, M.D., Assistant Professor of Clinical

Medicine, Cornell University Medical College 23

T E S T S OF PERSONALITY: WORD T E C H N I Q U E S A.

WORD ASSOCIATION TEST

577

By ROY SCHAFER, Ph.D., Staff Psychologist, Austen Riggs Foundation, Stockbridge, Massachusetts B. ROTTER INCOMPLETE SENTENCES BLANK . . . By JULIAN B. ROTTER, Ph.D., Professor of Psychology, Ohio State University; and JANET E. RAFFERTY, M.A., Research Assistant, Ohio State University 24

590

T E S T S OF PERSONALITY: RORSCHACH T E C H N I Q U E S A.

RORSCHACH TEST

599

By SAMUEL J. BECK, Ph.D., Lecturer in Psychology, University of Chicago; Lecturer in Psychology at Northwestern University; Consultant in Psychology, Institute for Psychosomatic and Psychiatric Research and Training, Michael Reese Hospital, Chicago B. INSPECTION RORSCHACH By RUTH L. MUNROE, Ph.D., Visiting Professor of Psychology, Graduate Division, College of the City of New York

611

xvi

CONTENTS

CHAPTER

25

PAGE

C. GROUP RORSCHACH By MOLLY R. HARROWER, Ph.D., Psychological Consultant, U. S. Army; Editor, "American Lecture Series in Psychology"

620

D. MULTIPLE CHOICE RORSCHACH By SAMUEL KELLMAN, Senior Clinical Psychologist, Adult Psychiatric Clinic, Harper Hospital. Detroit

625

T E S T S OF PERSONALITY : P I C T U R E AND D R A W I N G T E C H NIQUES A.

THEMATIC APPERCEPTION TEST

636

By HENRY A. MURRAY, M.D., Ph.D., Lecturer, Department of Social Relations, Harvard University; Formerly Director of the Harvard Psychological Clinic B. ROSENZWEIG PICTURE-FRUSTRATION STUDY

.

.

650

By SAUL ROSENZWEIG, Ph.D., Professor of Psychology,

Departments of Psychology and Neuropsychiatry, Washington University C. REVISED BENDER VISUAL-MOTOR GESTALT TEST . By MAX L. HUTT, Ph.D., Associate Professor of Psychology, University of Michigan

660

D.

688

HOUSE-TREE-PERSON DRAWING TECHNIQUE

.

.

By JOHN N. BUCK, Formerly Chief Psychologist, Lynchburg State Colony, Colony, Virginia 26

T E S T S OF ABSTRACT AND CONCRETE CONCEPTION A.

TESTS OF ABSTRACT AND CONCRETE BEHAVIOR .

.

702

By KURT GOLDSTEIN, M.D., Visiting Professor of Psychol-

ogy, Graduate Division, College of the City of New York; and MARTIN SCHEERER, Ph.D., Professor of Psychology, University of Kansas B. CONCEPT FORMATION TEST By EUGENIA HANFMANN, Ph.D., Lecturer on Clinical Psychology, Department of Social Relations, Harvard University

731

CONTENTS

xvii

CHAPTER

27

PAGE

T E S T S OF INTELLECTUAL A.

IMPAIRMENT

MEASURING T H E EFFICIENCY VARIABLE

.

.

.

741

By HARRIET BABCOCK, Ph.D., Consulting and Research Psychologist, New York City B.

SHIPLEY-INSTITUTE OF LIVING SCALE FOR MEASURING INTELLECTUAL IMPAIRMENT 751

By WALTER C. SHIPLEY, Ph.D., Professor of Psychology,

Wheaton College, Norton, Massachusetts C.

WECHSLER MEMORY SCALE

757

By ARTHUR WEIDER, Ph.D., Associate Professor of Medical

Psychology, Department of Psychiatry and Mental Hygiene, University of Louisville School of Medicine D.

HUNT-MINNESOTA TEST FOR ORGANIC BRAIN DAMAGE . .

760

By HOWARD F. HUNT, Ph.D., Associate Professor of Psy-

chology, University of Chicago E.

EXAMINING FOR APHASIA AND RELATED DISTURBANCES . . . . 766

By JON EISENSON, Ph.D., Director, Speech and Hearing Clinic, Queens College 28

O T H E R PSYCHOMETRIC INSTRUMENTS A.

WIDE RANGE A C H I E V E M E N T TESTS

772

By JOSEPH JASTAK, Ph.D., Chief Psychologist, Delaware

State Hospital, Farnhurst, Delaware B. By

KUDER PREFERENCE RECORD

782

FRANCES ORALIND TRIGGS, Ph.D., Chairman, Com-

mittee on Diagnostic Reading Tests, Inc., New York, and Assistant Director of the University of Maryland Counseling Center C.

VOCATIONAL INTEREST TEST FOR MEN AND WOMEN

By EDWARD K. STRONG, Jr., Ph.D., Emeritus

Professor

of Psychology and Director, Vocational Interest Research, Stanford University

789

xviii

CONTENTS D .

M E D I C A L C O L L E G E A D M I S S I O N T E S T

.

.

.

.

7

By JOHN M. STALNAKER, M.A., Director of Studies, Association of American Medical Colleges 29

PSYCHODIAGNOSTIC METHODS AT W O R K I T H E CASE OF GREGOR

806

By JOHN E. BELL, Ed.D., Associate Professor of Psychology, Clark University; and EDWARD L. SIEGEL, Ph.D., Psychologist, Cushing Veterans Administration Hospital, Framingham, Massachusetts INDEX OF N A M E S

847

INDEX OF S U B J E C T S

859

9

7

ILLUSTRATIONS FIGURE

PAGE

1. A diagram of the relativities of birth and age 52 2. Photograph of a human embryo, age eighteen days . . . . 52 3. Human embryo approaching fetal age of eight weeks, the stage when the first overt movements make their appearance . 52 4. Early stages in the ontogenetic patterning of prehensory behavior 53 5. The infant in the clinical crib is reacting to a standardized test situation . . . 68 6. Photographic dome for recording infant behavior patterns . 68 7. The method of cinemanalysis . . . . . . . 68 8. Left tonic neck reflex in infant age thirteen days, showing monocular fixation by right eye . 68 9. A three-year-old boy and a four-year-old boy arrange blocks . . 68 10. Developmental stages of prone behavior seriated to show alternations of flexor and extensor dominance leading ultimately to the upright posture . . 69 11. Diagram to illustrate the developmental principle of reciprocal interweaving in the ontogenesis of the upright posture . . . 64 12. A frequency polygon of heights of 6,194 adult English men . . 137 13. A frequency polygon of intelligence scores of 1,600 ninth grade students, as determined by nine different tests . . . . 139 14. A profile or psychograph showing one individual's rating on a variety of performances . . . 141 15. Incidence of symptoms of "maladjustment" in 100 unselected college students . . . . 143 16. Behavior of 2,114 motorists at corners with cross traffic and with boulevard stop signs . . . .144 17. Behavior of 208 motorists at corners with cross traffic but with no stop signs 145 18. Life chart of a patient with arthritis . . . 228 19. Life chart of a patient with duodenal ulcer 230 20. The mechanism of stress action 236 21. "Fright reaction" in the monkey 242 22. Effect of D C A upon the brain in the rat . . 242 23. Motor disturbances due to periarteritis nodosa of the brain . . 243 xix

xx

ILLUSTRATIONS

FIGURE

PAGE

24. Effect o f D C A u p o n t h e skull i n t h e r a t

243

25. V i e w of patient reclining o n laboratory table . . . . 2 6 . Differentiation of artifacts from actual contractions of the stomach wall by means of a simultaneous pneumographic tracing from the lower margin of the chest 27. A diagram of the thermal gradientometer for the measurement and recording of gastroduodenal blood flow 28. Correlation of color of gastric mucosa with gastric acidity-motor activity . . . . 29. C h a n g e s in g a s t r i c function a c c o m p a n y i n g appetite . . . . 30. C h a n g e s associated w i t h fear 31. A p e r s i s t e n c e of g a s t r i c a n a c i d i t y f o r t w o m o n t h s d u r i n g o v e r w h e l m i n g fear a n d d e j e c t i o n . 32. Sudden interruption of gastric contractions followed by nausea upon experiencing feelings of alarm, dejection, and hopelessness 33. Increased motility accompanying hyperemia and hyperacidity in association with hostility and resentment

290

34.

Sustained acceleration of gastric function during chronic emotional conflict . . .

35. The acceleration of acid production following contact of gastric juice with an eroded mucosa 36. Experimental production of an ulcer 37. Change in gastric secretions and motor activity induced during discussion of relevant conflicts 38. Variations in color of the gastric mucosa under a variety of circumstances before and after vagotomy 39. Acceleration of mucous secretion and inhibition of parietal secretion in response to the introduction of strong acid into the cavity of the stomach

291 291 292 292 294 295 296 298 299 300 300 301 305

306

40. Increased gastric motor activity and acid secretion during stress with sudden decrease in acidity following a phase of hypersecretion . . . . . . . . . 307 41. Duration of gastric digestion under various circumstances . . 308 42. Effect of benadryl during phase of gastric function . . . 310 43. Lack of effect following administration of benadryl during a phase of gastric hyperactivity related to situational stress . . . 311 44. Comparison of the effect of the gastric inhibitor urogastrone when administered during average circumstances and when the stomach was markedly hyperactive during anxiety and resentment following the receipt of a dispossess notice 312

ILLUSTRATIONS

xxi

FIGURE

PAGE

45. Sustained acceleration of gastric function (acid secretion and blood flow in the mucous membrane) during chronic emotional conflict 46. The gastrocolic reflex on a day of good spirits . . . .

321 326

47. The gastrocolic reflex in a phase of low spirits and dejection .

327

.

48. A progressive increase in tolerance of exercise (in a patient with patent ductus arteriosus) accompanying a progressive decrease in feelings of anxiety . . . . . . . 331 49. The changes in blood pressure and renal hemodynamics in three representative subjects . . 332 50. A comparison between the renal vascula resistances in hypertensive and normotensive subjects during stressful interviews . . 334 51. One type of cardiovascular reaction during frankly expressed anxiety . 335 52. A second type of cardiovascular reaction during frankly expressed anxiety . . . . 336 53. Diagrammatic representation in coronal and sagittal sections of the position of the turbinate bones and their appearance in various stages of swelling of their covering of mucous membranes and soft tissues . . . 339 54. Sustained hyperemia, swelling, hypersecretion, and obstruction in the nose during twelve days of anxiety and resentment, compared with control periods before and after 340 55. Changes in the reactive hyperemia threshold of both forearms of a healthy man in response to real and sham blows to the left forearm . . . . 341 56. Quantitative measurements of food intake and urinary output during three representative twenty-four-hour periods . . . 342 57. 58. Appearance of the temporal artery before and after termination of migraine headache by ergotamine tartrate . . . . 346 59. Headache induced during a discussion evoking feelings of hostility .347 60. Precipitation of a migraine headache in a woman following a stressful interview concerning her feelings of guilt and resentment toward her child . . . 347 61. The occurrence of nasal hyperfunction during inhalation of pollen accentuated by a discussion of relevant personal conflicts and dissipated during reassurance with relaxation, although pollen inhalation continued at the same rate . . 351 62. Lowered reactive hyperemia threshold while hives (urticaria) were developing, with return of the threshold toward normal as the hives disappeared 352

xxii

ILLUSTRATIONS

FIGURE

PAGE

63. Comparison of skin responses in a woman patient to stroking and to histamine and pilocarpine applied by electrophoresis before, during, and after a stressful interview . . . . . 353 64. Increase in facial sebum output during stressful interview inducing anger in an 18-year-old man with acne vulgaris . . . 354 65. Comparison of the occurrence of phasic changes in mood from anger to remorse with the daily pustule count on the face in an 18-year-old man with acne vulgaris 355 66. Hyperemia, hypersecretion, and swelling of the nasal structures during weeping—the reaction of "shutting out and washing away" 357 67. A suite for the developmental examination of infants and preschool children . . . . . . . .487 68. Examination arrangements adapted to advancing grades of postural control: supine, supported sitting, free sitting, and chair sitting 488 69. Examination materials . . 489 70. Examination chair for young infants 489 71. Clinical crib for developmental examinations 489 72. Specimen schedule from Gesell developmental schedules . . . 491 73. Maturation of normal and feeble-minded subjects in communication abilities . . . . . . . . 503 74. Maturation of normal and feeble-minded subjects in eating abilities 504 75. Maturation of normal and feeble-minded subjects in dressing abilities . . . . . . . . . . . 505 76. Schematized illustration of the curvilinear relationship between scores on Sc and severity of maladjustment . . . .551 77. A typical psychoneurotic profile 554 78. A typical psychotic profile 554 79. A typical conduct disorder profile 555 80. A typical psychosomatic profile 555 81. Case profile No. 1: female, age 28, divorced 557 82. Case profile No. 2 : male, age 29, married, university graduate student 562 83. Case profile No. 3 : male, age 27, married, university graduate student 84. Rorschach record filled in for Case A 85. Instructions for the Harrower Multiple Choice Rorschach Test . 86. Sample responses and answer sheet for the Kellman Multiple Choice Rorschach Test . 87. Test designs for the revised Bender Visual-Motor Gestalt Test .

563 616 626 628 662

ILLUSTRATIONS FIGURE

88. The figures of the color form sorting test (not in the presented random placement) . . 89. Examples of patients' performances on the color form sorting test 90. The object sorting test . 91. The stimulus figures in the stick test 92A. Example of patient's performances 92B. Example of patient's performances 93. Different design models of the cube test 94. Examples of wrong reproductions by patients with impaired abstraction . . . . . . . . . . 95. Characteristic reproductions of design models by patients . . 96. Concept formation test—unassorted 97. Concept formation test—assorted 98. Summary sheet from "Examining for Aphasia and Related Disturbances" . . . . 99. Profiles of means of scores on each scale of the Kuder Preference Record on general population norms . . . 100. Drawings of Gregor on (a) the Bender Visual-Motor Gestalt Test and (b) the Ball and Field Test . . . . 101. Drawings of a woman and a man by Gregor . . . .

xxiii PAGE

703 705 710 714 716 717 718 722 723 726 726 769 787 816 820

TABLES PAGE

Components of personality . .108 Clinical diagnostic levels of intelligence by I.Q. as determined by the Stanford-Binet (1937) and the Wechsler-Bellevue Scale . . . 464 The growth complex . 493 Vineland Social Maturity Scale 497-500 Relation of W.I.S.C. I.Q.'s to percentile rank 525 Intelligence classifications . . . 525 Test characteristics of various clinical groups adapted from Wechsler . 541 Sections on the Cornell Medical Index . . . . 571 Average number of items noted in each Cornell Medical Index and in each hospital history . . . 572 Comparison of the average number of diagnostic areas per patient in which diseases were identified in hospital investigation and with the Cornell Medical Index . 573 Cumulative frequency distribution of the number of "yes" responses on the C.M.I, for five samples of men . . . 575 Cumulative frequency distribution of the number of "yes" responses on the C.M.I, for four samples of women 576 Standardization population for the Rorschach Test 604 A Rorschach Test psychogram 605 Scoring components of the Picture-Frustration Study . . . . 654 Vocabulary and abstraction items . . . . . 752 Means and standard deviations of scores for physicians on Form C of the Kuder Preference Record and percentile ranks of the mean scores, using norms for the general population . . 786 Means and standard deviations of scores for nurses on Form B of the Kuder Preference Record and percentile ranks of the mean scores, using norms for the general population . . . 786 Scores of a design engineer and of a chemist, Strong Vocational Interest Test . . . . 793 Scores of a chemist and correlations between profiles on the Strong Vocational Interest Test . . . 794 [ntercorrelations among the reported scores on the four sections of the Medical College Admission Test, Form XMC, based on a sample of 500 cases 800 XXV

PART I PSYCHOLOGY AND MEDICINE

Chapter 1 THE PROFESSION OF PSYCHOLOGY AS SEEN BY A DOCTOR OF MEDICINE 1 By ALAN GREGG,

M.D.

Introduction MINDFUL OF THE FACT that honors are often bestowed with more of generosity and hope than of discernment and justification, I must further qualify my gratitude for the honor of addressing you on psychology as seen by a doctor of medicine with the declaration that I have no mandate from my medical brethren to speak for them, nor are my views to be taken as the views of the majority of medical men. They may be; I have no basis for implying that they are. Oscar Wilde, I believe, observed that all criticism is a form of autobiography. Perhaps my only experience that in any appropriate manner or measure may qualify me to speak of a physician's view of psychology was a share in the preparation of the report of the Harvard Commission on The Place of Psychology in an Ideal University. It was a commission in which the doctors of medicine were outnumbered 9 to 3, and therefore they may be suspected of having accumulated a few of what the French call "pensees d'escalier"—the things you wish you had been bright enough to think of at the proper time instead of their coming to mind only as you descend the stairs after the affair is all over. Let us lose no more time, however, in getting around to talking about a most interesting subject—your own profession. Since there seems little or no evidence that either my profession or yours is prepared to absorb the other, any discussion of the relationships of medicine and psychology naturally turns to the consideration of what they have in common, what each possesses uniquely, and what may be available for export and import to and from each other. Psychology as a profession is young. Now it is notoriously difficult to apprise youth of the delights of being young. So medicine 1 Special address given by invitation of the American Psychological Association at Boston, September 8, 1948.

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CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY

might well envy psychology its present freedom to chart its course, make its promises, and find its friends. "Never forget," wrote Wordsworth to Lady Beaumont, "that every great and original writer in proportion as he is great and original must himself create the taste by which he is relished." 2 As psychologists you are in the enviable position of having a similar freedom to create the taste by which your work is to be relished. You can deliberately create the demand for what you have learned how to do, after you have learned how to do it. Medicine has so often had to follow another sequence—surrounded from the first by sufferers demanding relief from pain or disease and even with death itself plucking at the doctor's sleeve, we have had to find out how to meet an already existing demand. In the main the psychologist does not work in the atmosphere of crisis—birth, terrifying weakness, or the fear of death. Does your freedom from such tensions cheat you of a certain stern discipline that is salutary? Since you are spared the contagious anxiety of dependent patients, will you feel any gratitude for that dispensation? What form might such gratitude take ? Is it reasonable to ask how will you spend this magnificent leisure? Medicine might naturally envy another consequence of the relative youth of psychology—though perhaps not for long. The established facts and the desirable skills in medicine have become perplexingly numerous; medical education is now overloaded with the task of imparting so much that is already known and known to be valuable. In medicine, for example, morphology plays a relatively larger role than I suppose it plays in psychology, and I do not see the analogue in psychology of the demand in medicine for a knowledge of parasites and other invading organisms. Your energies, like those of the physiologists, can and do go admirably deeper into the formulation of theories to explain function. I do not think that your task is the easier: indeed, like youth, you have even more occasion for wisdom because your course is still within your control. To pass from envy to admiration, the more reflective physician finds the horizon of the psychologist refreshingly wide in its inclusion of man's social relationships and his societal behavior. Only recently has any comparable interest in social medicine found explicit academic support—the Chair of Social Medicine at Oxford. You have a wonderfully wide expanse ahead in social psychology. To an admirable degree, psychology has insisted that the trees shall obscure neither its forest nor even its horizon. 2 William Knight Douglas (ed.), Memorials of Coleorton (Edinburgh, 1937), II, 17.

THE PROFESSION OF PSYCHOLOGY

5

What Psychology Contributes to Medicine No less admirable has been the example set by psychologists in one of the general problems of science—the problem of the observer. If sophistication ever can be refreshing, the sophistication of the psychologist in allowing for the individual observer's reaction time, his inadvertences, his distractions as a witness, and his flaws of memory, is a refreshing sort of sophistication, well worth further refinement and spirited insistence. Medicine has much to learn from your new contributions to the problem of the observer. Because psychology takes experience as well as behavior and thinking as its province, it places a valuable emphasis upon narrative as well as descriptive exposition. Possibly the present wealth of laboratory tests has led the doctor too far away from the narrative form : certainly most of today's doctors know what tests to ask of the laboratories better than they know how to elicit really adequate histories from their patients. From psychology, medicine could learn that statistical analysis offers the only scientific correction of variables that mislead the na'ive suggestibility of a prejudiced observer. Phenomena vary with a sort of Brownian movement; only statistical critiques will prevent a similar Brownian movement among the saltatory little explanations of varying phenomena. Not only in the critical interpretation of variant data but also in the creative task of eliciting answers from experiments you are adroit. Medicine, and particularly psychiatry, could wTell look to psychology for skill in designing conclusive experiments and match your insistence upon the importance of explicit and predetermined methodology in experimental work. I do not happen to believe that experimental verification is the only hallmark of dependable scientific hypotheses. Where would geology and astronomy be without the alternate test of hypotheses—the validation that comes from the fulfilment of accurate prediction ? But I do happen to believe that psychologists have a signal opportunity to teach doctors by example and by precept how to formulate and test hypotheses regarding the phenomena of human behavior. The late Douglas Singer suggested that in the course in physiology for medical students at the University of Illinois, after the physiology of various organs and organ systems had been presented, there should be at least six lectures on the physiology of the organism as a whole. These lectures could begin with tropisms, pass to certain patterns of instinctive behavior, and perhaps end with considering the integrative role of emotions, learning, and memory. The modest raison d'etre

6

CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY

of such lectures was the assumption that in addition to the physiology of various organs there is truly a physiology of our old friend, the organism as a whole. The very novelty of that suggestion to most physiologists points to the likelihood that medicine could profit from more of the integrative view which you psychologists have long taken. Indeed your view has been so comprehensive that you have accepted irrational behavior as part of significant reality. In this you have furnished medicine with a splendid example and a new province to explore—I say "new" because so many doctors if given to translate the dictum nihil humanum alicnum nrihi puto, would be disposed to render it as "nothing that belongs to the alienist do I think of as human." I should like to see all doctors who believe they understood the implications of Sherrington's illuminating title. The Integrative Action of the Nervous System, reflect for, say. five whole minutes on the integrative effect of a knowledge of modern psychology. Not only can medicine learn from psychology; it already depends on the psychologists for help and expects confidently that you will be able to extend and perfect this help. I refer, of course, to the task of selecting medical students and the psychological testing of patients. When an American medical school of not exceptional distinction has to select 72 first-year students from 1,205 applicants—a situation recently described to me—you can realize that medicine is in a position to welcome any aid it can receive in the selection of its future practitioners, investigators, and teachers. Psychiatrists of any competence realize that your aid in the appraisal of their patients is already indispensable. And I think you may as well delicately realize that the collaboration of a well-trained psychologist helps to temper and balance the judgment of the psychiatrist and so protects him from the possible abuse of his highly concentrated power over the lives of others. One more contribution of psychology to medicine deserves emphatic mention: medical education is a form of education, not a mere initiatory apprenticeship. As I am convinced that the contribution of psychology to education will be one of the greatest benefits it could confer, so I am convinced that quite apart from clinical psychology, medicine will profit by the changes psychology can bring in medical education, that extraordinarily intimate blend of acquiring knowledge by experience as well as by the written and spoken word. We know too little of the wisest forms of teaching medicine. Can you help us ?

THE PROFESSION OF PSYCHOLOGY

7

What Medicine Contributes to Psychology Now in interprofessional relationships it is manifestly more blessed to be accused of giving than it is to prepare one's self to receive what the other profession may offer. And the task of describing what medicine might be able to contribute to psychology becomes more delicate when I reflect how hard it is to communicate the best of what medicine can offer even to our medical students and our patients, and in what short supply we stand of such advantages as might be worth offering you. Without doubt the medical profession can draw upon a long experience as a profession. So can most of the major religions. In neither case is mere age a guarantee of excellence, though it does suggest vitality. Besides, long experience is of less import in an adaptive society than it would be in a society governed by tradition and undisturbed by change. Probably as the application of psychology increases in range and effectiveness, psychotechnologists, clinical psychologists, and others who apply psychology to various human activities will increase in numbers and in status. Indeed problems of training and licensure already press upon you. But you will have other professional problems, of professional organization, of ethical codes, of professional behavior, of professional self-government, of disbarment, of recruitment, certification, of institutional management, and of your status in society at large. In such matters I would suggest that a comparative study on your part of medical, legal, educational, and religious professional associations and their methods of solving given problems would now be of considerable value to your rapidly growing profession. Rapid growth is not always accompanied by rapid or effortless maturing. A generation ago Dr. Abraham Flexner set down certain criteria for judging whether an occupation has attained professional status or not. According to his interpretation of the professions: (1) they involve essentially intellectual operations accompanied by large individual responsibility; (2) they are learned in nature, and their members are constantly resorting to the laboratory and seminar for a fresh supply of facts; (3) they are not merely academic and theoretical, however, but are definitely practical in their aims; (4) they possess a technique capable of communication through a highly specialized educational discipline; (5) they are self-organized, with activities, duties, and responsibilities which completely engage their participants and develop group consciousness; and finally (6) they are likely to be more responsive to public interest than are unorganized and iso-

8

CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY

lated individuals, and they tend to become increasingly concerned with the achievement of social ends.3 One aspect of the medical practitioner's daily experience is, I am almost sure, worth passing on to you. In the constant obligation to give a prognosis as well as a diagnosis, medicine has an experience to offer whose effect escapes too often the attention it deserves. No other professional men seem quite so steadily expected to call the turn of coming events as are the doctors of medicine. This obligation has a special effect upon those who meet it. For the use of those branches of psychology that do not employ exclusively the experimental method, I would think it particularly valuable for you to insist on a much more frequent and detailed exercise of the faculty of prognosis. Certainly I can testify to the sobering and the clarifying effect of this practice in the lives of medical men. Nothing else quickens one's interest in the subsequent history of a disease and alerts one's attention to the operating factors controlling any single case as does the obligation to forecast its future course. From the side of medicine I would call the attention especially of social psychologists to the heuristic value of the act of prognosis. Like betting, prognosis does not control the event, but it does increase one's interest in all that enters into the final outcome. More important, however, than the clinician's obligation to give a prognosis is his characteristic task of discovering, assembling, and weighing heterogeneous evidence. You are probably familiar with the remark that performing an experiment is cross-examining Nature, but first-rate clinical observation is overhearing Nature babbling to herself. No person of experience would deny that priceless surprises may be received by overhearing—hints, suggestions, cues so gloriously new that no cross-questioner could have imagined them. No doubt that to be a discovering listener requires exquisite sensitiveness and a lovely freedom of imagination. But it is so evident that what you know or think obscures and limits what you can observe, that I plead with you to regard the amazing receptivity of the clinician at his best. I plead with you because I believe that the greatest handicap to the study of human beings is unconscious preconceived notions. Many a hypothesis is accompanied by preconceived notions, and these may dull our general perceptiveness and blind us to the context and the circumstances of the event observed. And I plead with you because of the defect of your excellent quality of preoccupation with hypotheses. You are likely to suffer from this preoccupation, for 3 Sec Is social work a profession?, Proceedings of the National Conference of Charities and Correction, 1915, pp. 578-81.

THE PROFESSION OF PSYCHOLOGY

9

which the clinician's apparently unorganized sensitiveness to all the circumstances and to the unexpected is the only safeguard. Young sciences suffer from such preoccupation, while old sciences profit from contemplating stubborn, disconcerting, unexpected, and disorganized facts. Clinical experience and responsibility create a unique and ineradicable imprint that deserves your attention. It takes no more than a few months for a young doctor to acquire a new picture of himself. He finds both that he is considered responsible and that he is responsible for human conduct and his patients' lives. It is the most unforgettable experience. I have wondered sometimes if psychologists ever undergo as impressive an experience when they are preparing themselves to deal with human beings. Sooner or later, with better reasons or worse, the young doctor is faced with the responsibility for a death, or a life of invalidism, that need not have occurred. The Greeks knew that there were only two kinds of people who could kill human beings with impunity—doctors and judges. So grave and at times paralyzing is this burden of medical responsibility that I would hope that clinical psychologists for their peace and freedom of mind will never have to face it, but they will none the less have its analogue in the responsibility they share for the happiness and health of patients. Let them realize from early on that an obsessive search for the causes of a symptom is not always enough. They may find it wiser, as Whitehorn says, to find the meaning of a symptom rather than to find its causes. Another implication of dealing with patients can be borrowed from the experience of medicine. It is none too common in medicine, and it is perhaps more prevalent in psychology than I have had occasion to remark. I refer to the opportunity in therapy to evoke a patient's unused or undiscovered potentialities. Certainly this marks much of the work of psychologists engaged in guidance and counseling. Such liberation of the energies and enthusiasm of others by means of psychological knowledge can occur outside as well as inside the consultation room or the hospital ward, and consequently the applications of psychology can have the cheerful atmosphere of hygiene and healthy growth. In medicine, the pediatricians have, par excellence, a heartening satisfaction in witnessing the vis mediatrix naturae. I hope psychologists may know in ever increasing measure the delights of finding out how to heighten the pleasures of being alive. Perhaps you are beyond the rest of us qualified to learn and teach what makes for sound and exuberant living.

io

CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY

What Medicine and Psychology Have in Common And now having noted what medicine and psychology could offer each other, let us turn to what they have in common. Like various branches of medicine that started as merely descriptive sciences, later to become preoccupied with etiology and problems of causation, and at long last turning to what I would call the evocative—evoking all their knowledge for positive health as well as the prevention or alleviation of disease—the different branches of psychology are on their way in what seems to me a similar series of developments. In putting into effect recommendations for the clinical or intern year of training, psychology will share with medicine the extraordinary stimulus of the hospital experience. In the quantity of hospital work, in its variety brought out by easy and constant comparisons, and in the variety of problems posed, the hospital has tremendously influenced the teaching and the growth of medicine—and its popular support. I would predict a similar result for the intern year on the profession of psychology—including popular support and understanding. Nor can one imply that what we have in common is all satisfactory. We share some defects too. Medicine and psychology share a neglect of genetics which is perhaps best described by saying that they seem to think that heredity is a study of one's uncontrollable ancestors, whereas it is one of the few fields that offers any dependable control over one's descendants. Our failure to understand events in Europe is due in part to the fact that few in this country seem to realize that the greatest losses of the last two wars are genetic. Such losses do not affect the past. They affect the present and future. When will the gene-determined aspects of behavior come in for proper attention? In my opinion we grossly underestimate the importance of hereditary factors in human behavior, as well as in human medicine. And in all humility wre must admit to a common and a general fault. Both medicine and psychology should accept their share of the besetting sin of the scientific mind, namely that it believes that the equation it writes to represent reality contains all the factors that are involved. I think that the equation A plus B = C should be written A (plus x or minus y) plus B (plus ^ or minus r) = C (plus q or minus c). Or in more literary and familiar terms, "There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy." In short, we must be forever on the alert for the hidden factors that may be in our equations. We need a feeling for context.

THE PROFESSION OF PSYCHOLOGY

n

Lastly, psychology as well as medicine must realize this inescapable sequence: study discovers knowledge, knowledge brings power, power entrains responsibility, and responsibility must be prepared to survive praise or blame, dependence or passionate resentment. One can see this sequence in the history of physics, from Archimedes to the atomic bomb: study, knowledge, power, responsibility. If this is the sequence in our knowledge of the physical world, can we expect the history of psychology to follow a different course? I think not. It may be a tragic history or it may be magnificent. Whatever its future may be, psychology will sooner or later have to face the responsibility that comes from power.

Chapter 2 THE PSYCHOLOGICAL ASPECTS OF MEDICINE By FRANZ ALEXANDER,

M.D.

Historical Perspective ONCE AGAIN, the patient as a human being with his worries, fears, hopes, and despairs, as an indivisible whole and not only as the bearer of organs—of a diseased liver or stomach—is becoming the legitimate object of medical interest. In the last two decades, increasing attention has been paid to the causative role of emotional factors in disease, and a growing psychological orientation manifests itself among physicians. Some sound and conservative clinicians deem this a threat to the so arduously acquired scientific foundations of medicine, and authoritative voices warn the profession against this new "psychologism" as incompatible with medicine as a natural science. They would prefer that psychological medicine should remain restricted to the field of medical art, to tact and intuition in handling the patient, as distinct from the scientific procedure of therapy proper, which is based on physics, chemistry, anatomy, and physiology. From a historical perspective, however, this psychological orientation is nothing but a revival of old prescientific views in a new and scientific form. It was not always that the care of the suffering man was divided between the priest and the physician. At one time the healing functions, whether mental or physical, were united in one hand. Whatever the explanation of the healing power of the medicine man or of the evangelist or of the holy water of Lourdes might be, there is little doubt that they often had a spectacular curative effect upon the sick, in certain respects even a more fundamental effect than many of our drugs, which we can analyze chemically, and the pharmacological effects of which we know with great precision. This psychological portion of medicine survived only in a rudimentary form as medical art and bedside manner, carefully separated from the scientific aspects of therapy, and is considered mainly as the suggestive, reassuring influence of the physician upon his patient.

PSYCHOLOGICAL ASPECTS OF MEDICINE

13

Modern scientific psychological medicine is but an attempt to place medical art, the psychological effect of the physician upon the patient, on a scientific basis and to make it an integral part of therapy. There is little doubt that much of the therapeutic success of the healing profession, of the medicine man and of the priest, as well as of the modern practitioner, has been due to the undefined emotional rapport between physician and patient. This psychological function of the physician, however, was perhaps never more disregarded than in the last century, in which medicine became a genuine natural science based on the application of the principles of physics and chemistry to the livingorganism. The fundamental philosophical postulate of modern medicine is that the body and its function can be understood in terms of physical chemistry, that living organisms are physiochemical machines, and that the ideal of the physician is to become an engineer of the body. The recognition of psychological forces, a psychological approach to the problems of life and disease, appears as a relapse back to the ignorance of the Dark Ages, in which disease was considered as the work of the evil spirit and therapy was exorcism, the expelling of the demon from the diseased body. It is only natural that the new medicine based on laboratory experiments jealously defended its newly acquired scientific halo against such antiquated mystical concepts as those of psychology. Medicine, this newcomer of the natural sciences, in many respects assumed the typical attitude of the newcomer who wants to make himself forget his low origin by becoming more intolerant, exclusive, and conservative than the genuine aristocrat. Medicine became most intolerant toward everything which might have reminded it of its spiritual and mystical past at a time when the aristocrat of the natural sciences, its older brother, physics, was undergoing the most profound revolution of its fundamental concepts, questioning even the shibboleth of science, the general validity of determinism. These remarks, however, are not intended to minimize the accomplishments of the laboratory period in medicine, which represents the most brilliant phase of its history. The physicochemical orientation characterized by the precise study of fine details is no doubt responsible for the great progress displayed by modern bacteriology, surgery, chemotherapy, and pharmacology. It belongs to the paradoxes of historical development that the greater the scientific merits of a method or a scientific principle, the greater will be the retarding influence in a later, more advanced period of development. The inertia of the human mind makes it stick to the ideas and methods which have proved of great value in the past even though their usefulness

i4

CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY

has already served its term. The development of the most exact of sciences, physics, is full of such examples. Progress in every field requires a reorientation and the introduction of new principles. These new principles, although actually not always contradictory to the old ones, nevertheless are often rejected and must struggle for their recognition. The scientist in this respect is just as narrow-minded as the man on the street. The same physicochemical orientation of the laboratory era to which medicine owes its greatest accomplishments has become, on account of its one-sidedness, an obstacle to further development. This new scientific laboratory era of medicine is characterized by its analytic attitude. Typical of this period is a specialized interest in detailed mechanisms, in the understanding of partial processes. The discovery of finer methods of observation, especially the microscope, disclosed a new microcosm in giving an unprecedented insight into the minute parts of the body. Accordingly in etiology, in the study of the causes of the diseases, the principal aim became the localization of the disease. Ancient medicine was governed by the humoral theory, according to which the fluids of the body were claimed as the carriers of the diseases. The gradual development of the methods of autopsy during the Renaissance made possible a precise study of the details of the human organism and thus led to more realistic but at the same time more localistic etiological concepts. Morgagni at the end of the eighteenth century claimed that particular organs, such as the heart, the kidney, or the liver, were the seat of the diseases. With the introduction of the microscope the localization of the disease became even more narrowed down : the cell became the seat of disease. No one was more responsible for this particularistic concept in medicine than Virchow, to whom pathology owes more than to anyone else. He declared that there are no general diseases, only diseases of the organs and of the cells. His great achievements in the field of pathology and his great authority made of cellular pathology a dogma which has influenced medical thinking up to the present day. Virchow's influence upon etiological thought is the classic example of the above-mentioned paradox of history. The greatest accomplishments of the past become later the greatest obstacles against further development. The discovery by the help of the microscope of histological changes in diseased organs became the universal pattern for etiology. The search for the causes of diseases long remained limited to attempts to discover local pathological changes in the tissues. The concept that such local anatomical changes are but the immediate cause and themselves might be results of more general disturbances, which develop as the effect of faulty

PSYCHOLOGICAL ASPECTS OF MEDICINE

15

functioning, overstress, or even emotional factors, had to be discovered later. The less particularistic humoral theory which became discredited when Virchow successfully defeated its last representative, Rokitansky, had to wait for its revival in the form of modern endocrinology. Few have understood the essence of this phase of medical development better than Stefan Zweig (6), a layman. In his book Mental Healers he says: Disease meant now no longer what happens to the whole man but what happens to his organs. . .. And so the natural and original mission of the physician, the approach to disease as a whole changes into the smaller task of localizing the ailment and identifying it and ascribing it to an already specified group of diseases. .. . This unavoidable objectification and technicalization of therapy in the nineteenth century came to an extreme excess because between the physician and the patient became interpolated a third entirely mechanical thing, the apparatus. The penetrating, creative, synthesizing grasp of the born physician became less and less necessary for diagnosis . . . Not less impressive is the statement of Dr. Alan Gregg (4), a man who views the past and future of medicine from a broad perspective : The totality that is a human being has been divided for study into parts and systems; one cannot decry the method, but one is not obliged to remain satisfied with its results alone. What brings and keeps our several organs and numerous functions in harmony and federation ? And what has medicine to say of the facile separation of "mind" from "body"? What makes an individual what the word implies—not divided? The need for more knowledge here is of an excruciating obviousness. But more than mere need, there is a foreshadowing of changes to come. Psychiatry is astir, neurophysiology is crescent, neurosurgery flourishes, and a star still hangs over the cradle of endocrinology. .. . Contributions from other fields are to seek from psychology, cultural anthropology, sociology, and philosophy as well as from chemistry and physics and internal medicine to resolve the dichotomy of mind and body left us by Descartes. The Role of Modern Psychiatry in the Development of Medicine It was reserved to the most neglected and least developed portion of medicine, to psychiatry, to introduce a new synthetic aspect into medicine. For a long time during the laboratory period, psychiatry

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remained a rather isolated domain which had little contact with the rest of medicine. It was concerned with the mentally diseased, a field in which the usually accepted methods of medicine proved to be much less productive than in all other fields. The symptomatology of the mental disturbances unpleasantly differed from the disturbances of the body. Psychiatry had to deal with delusions, hallucinations, and the disturbances of the emotional life. These symptoms did not permit even a description in the usual terms of medicine. Inflammation can be described in physical terms: swelling, increased temperature, and definite changes in the cells observable under the microscope. Tuberculosis is diagnosed by definite changes in the afflicted tissues and the presence of well-defined micro-organisms. The pathological mental functions, however, had to be described in psychological terms. Since the functions of the mind roughly could be connected with brain functions, the interest turned toward the histological study of the brain tissue of deceased psychotics, and histopathology became the scientific basis of psychiatry. Unfortunately—or perhaps from the point of view of progress, fortunately—in most cases of even severe mental disturbances no constant pathological changes could be discovered in the brain. It was only natural that one hoped for light to come from a further advancement of knowledge of the cellular physiology of the brain. Even though one could not find gross pathological changes in the brain, one expected that with the progressive refinement of investigative methods one would be able to find that basis of psychological disturbances in the disturbed function of the brain cells. Theoretically, of course, the validity of this expectation is undebatable. A powerful reinforcement of these hopes came from the discovery of the infectious nature of general paresis. Although there was still a big gap to be bridged between the tissue changes and the psychological symptoms of general paresis, a new hope arose from the understanding of mental disturbances on the basis of pathological anatomy of the brain. However, the next step toward the solution of the mysteries of the diseased mind came from another source, from the psychoanalysis of Sigmund Freud. We have seen that clinical psychiatry tried to approach the problems of mental disturbances by the help of the microscope, and in this effort became disinterested in the very essence of its own field, in psychological phenomena. The solution of these problems required, however, another type of microscope, a psychological microscope. When medicine, this newest of all natural sciences, developed a definite distaste for the psychological aspect of the living organisms, it naturally transferred this attitude toward psychiatry, which out of

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necessity had to deal with mental phenomena. Physicians felt instinctively that this was the weak spot where the old medieval demonology threatened to creep again into medicine. Psychiatry with its psychological problems became the stepchild of medicine and was not considered as equal to the other fields but rather a foreign body threatening the purity of scientific medicine, which has fully adopted the methods of physics and chemistry. Psychiatrists in self-defense made strenuous efforts to make the rest of their colleagues accept them as equals and overemphasized their nonpsychological attitude. They did not want to be considered as mental healers but as physicians like the other specialists, engineers of the body. They refused even to take cognizance of the existence of psychic problems. Psychological symptoms were only considered in so far as they served for the classification of certain diseases, as in the system of Kraepelin, but no attempt was made to study their meaning. Life, however, is stronger than theories. There was the large number of mental sufferers who did not profit from the laboratory studies of the scientists and wanted help. The severe cases, the psychotics, were considered generally beyond help. Being often apathetic and deeply submerged in their ailment, they did not rebel against this disregard of their needs. But the even vaster group of milder cases, the psychoneurotics, who constitute probably the majority of all human sufferers, wanted help. One of the saddest anomalies of medical history developed. The physician whom these patients forced to listen to their psychological complaints, who was unable to understand and to handle these symptoms with his one-sided laboratory equipment, began to dislike this type of neurotic patient. In order to hide his ignorance, he refused to consider them as really sick and accused them of malingering. In order to defend their scientific aura, physicians had developed a distaste for psychological facts, and now they turned this distaste against their psychoneurotic patients. The psychoneurotic patient was regarded as a nuisance and felt as a living accusation against the inadequacy of prevailing methods and dogmas. The hysterical patient played a cruel joke on his physician, indeed. He developed nervous symptoms which seemingly did not follow the laws of anatomy and physiology. He developed bodily symptoms of the kind which did not correspond to the distribution of the nerves but to morbid ideas, thus demonstrating the superiority of the "mind" over the "body." In response, the physician became impatient with the nervous sufferer and stubbornly refused to deal with his symptoms °n a psychological level.

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This was the situation in which the young Freud, influenced by Charcot's hypnosis experiments, decided to earn his living by giving real help to the psychoneurotic. For this purpose he felt he must understand the nature of the neuroses. The end results of this endeavor were known as the psychoanalytic therapy, together with a new contribution to the knowledge of man. The Contributions of Psychoanalysis, Psychology, Neurology, and Endocrinology We are not concerned here with the details of the psychoanalytic theory or with the technique of psychoanalytic therapy. There exists a vast scientific and popular literature of this field, both defending and attacking this new approach to the problem of life and disease. How much of the original concepts will survive, be modified, or be abandoned must be left for the future. Psychoanalysis as a theory of personality reaches beyond the realm of medicine into all fields which are concerned with human behavior—the fields of anthropology, social sciences, and the problem of education. As a therapy of nervous disorders, it has its definite limitations, as all forms of therapy do. Its influence on medical thought in general, however, can be well defined already. Historically viewed, the development of psychoanalysis can be considered as one of the first signs of a reaction against the one-sided analytical development of medicine in the second half of the nineteenth century, against the specialized interest in detailed mechanisms, against the neglect of the fundamental biological fact that the organism is one unit and the function of its parts can only be understood from the point of view of the whole system. The laboratory approach to the living organism disclosed an incredible collection of more or less disconnected details, and this inevitably led to a loss of perspective. The fact that the organism is a most ingenious mechanism in which every part cooperates for definite purposes was not only neglected but defamed as an unsound teleological point of view. It was claimed that the organism develops through certain natural causes, but not for a certain purpose. A man-made machine, of course, can be understood on a teleological basis; the human mind creates it for a certain definite purpose. But man was not created by a supreme intelligence—this was just the mythological concept from which modern biology fled, insisting that the animal body should not be understood on a teleological but on a causal and mechanistic basis. As soon, however, as medicine, nolens volens, turned toward the

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problem of the diseased mind, this particularistic attitude—at least in this field—had to be abandoned. In what we call personality, the fact that the organism is an intelligibly coordinated unit comes to such striking expression that it cannot be overlooked. William White (5) expressed this fact in simple terms. The answer to the question, What is the function of the stomach ? [is that it] is digestion, which is but a small part of the activity of the total organism and only indirectly, though of course importantly, related to many of its other functions. But if we undertake to answer the question, What is the man doing ? we reply in terms of the total organism by saying, for example, that he is walking down the street or running a foot race or going to the theater or studying medicine or what not. . . . If mind is the expression of a total reaction in distinction from a partial reaction, then every living organism must be credited with mental, that is, total types of response. .. . What we know as mind in all its present infinite complexity is the culmination of a type of response to the living organism that is historically as old as the bodily types of response with which we are more familiar. . . .

Personality thus can be defined as the expression of the unity of the organism. As a machine can only be understood from its function and purpose, the understanding of the synthetic unit which we call body can only be fully understood from the point of view of the personality, to the aims and purposes of which, in the last analysis, all parts of the body are subjected in an intelligible coordination. Psychiatry as the study of morbid personality, therefore, necessarily was to become the gateway for the introduction of the synthetic point of view into medicine. But psychiatry could only accomplish this function after it had discovered the personality as its main topic, and this was the accomplishment of Sigmund Freud. Psychoanalysis consists in the precise, detailed study of the development and functions of the personality. Although, somewhat paradoxically, the expression "psychoanalysis" contains the word "analysis," yet its historical significance consists in its synthetic influence. Psychoanalysis, however, was not the only scientific movement toward synthesis. The development of scientific methods in all fields during the last century resulted in an eager collecting of data. Discovery of new facts became the highest goal; their interpretation and correlation in the form of synthetic concepts was looked upon with suspicion as unsound speculation or philosophy in contrast to science. As a reaction to this excessively analytic orientation, a strong desire for synthesis appeared as a general trend of the last decade.

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Thus, for example, this new synthetic trend can also be clearly observed in nonmedical psychology. Here too the tradition of the nineteenth century was the analytic approach. After the introduction into psychology of the experimental method by Fechner and Weber, psychological laboratories sprang up in which now the human mind was dissected into its parts. There developed a psychology of vision, of hearing, of the tactile sense, of memory, of volition. But the experimental psychologist never even tried to understand the interrelationships of all these different mental faculties and their integration, which we call the human personality. Kohler's, Wertheimer's, and Koffka's Gestalt psychology can be regarded as a reaction against this particularistic analytic orientation. Probably the most important accomplishment of these Gestalt psychologists has been the clear formulation of the thesis that the whole is not the sum total of its parts but something different from them and that from the study of the parts alone the wrhole system never can be understood. Just the opposite is true: the parts can be thoroughly understood only after the meaning of the whole has been discovered. In medicine, a similar development took place. The advances in the field of neurology paved the way for a more comprehensive understanding of the relationships between the parts of the body. It became more and more evident that in the last analysis all parts of the body directly or indirectly are connected with a central governing system and are under the control of this central organ. Not only the voluntary muscles but all the vegetative organs, via the so-called autonomic or vegetative nervous system, are connected with the highest centers of the nervous system. The unity of the organism is most clearly expressed in the functions of the central nervous system. The central nervous system has both the function of the regulation of the internal vegetative processes of the organism and also the regulation of its external affairs, its relations to the environment. The integration of all the external and internal affairs of the organism is the function of a central government, represented by the highest centers of the nervous system, which in human beings we call the personality. In fact it became obvious that the physiological study of the highest centers of the central nervous system and the psychological study of personality deal with one and the same thing from different points of view. Whereas physiology approaches the functions of the central nervous system in terms of space and time, psychology approaches it in the terms of those subjective phenomena which we call psychological, and they are the subjective reflections of physiological processes.

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Another stimulus for the synthetic point of view came from the discovery of the ductless glands, a further step toward the understanding of the extremely complicated interrelationships between the different vegetative functions of the organism. The system of the ductless glands can be considered also as a central regulating" system similar to that of the nervous system; whereas the governing influence of the central nervous system takes place through the conduction of regulating nervous impulses via the peripheral nerve trunks to the different parts of the body, the chemical control of the ductless glands takes place through the conduction by the blood stream of certain chemical substances. Recently more and more evidence is emerging that probablv the functions of the ductless glands ultimately are also subject to the function of the highest centers of the brain, that is to say, to the psychic life. These physiological discoveries gave us an insight into the detailed mechanism of the fundamental details of how the mind rules the body. The fact that the mind rules over the body, no matter how much it was neglected by biology and medicine, is the most fundamental fact which we know about the process of life. It is the fact which we observe continuously during all of our life. From the moment when we awaken every morning, our whole life consists in carrying out voluntary movements aimed at the realization of certain ideas, wishes, the satisfaction of subjective feelings such as thirst and hunger. Our body, this complicated machine, carries out most complex and refined motor activity under the influence of such psychological phenomena as ideas and wishes. The most human of all bodily functions, speech, is nothing but the expression of ideas through a refined musical instrument, our vocal apparatus. All our emotions we express by physiological processes : sorrow, by weeping ; amusement, by laughter ; and shame, by blushing. All emotions are accompanied by physiological changes: fear, by heart palpitation; anger, by increased heart activity and elevation of blood pressure and a change in carbohydrate metabolism; despair, by a deep inspiration and expiration called sighing. All these physiological phenomena are the results of complex muscular interaction under the influence of nervous impulses, carried to the expressive muscles of the face and to the diaphragm in laughter, to the lachrymal glands in weeping, to the heart in fear, and to the adrenal glands and to the vascular system in rage. All these nervous impulses arise in certain emotional situations during our life in our interaction with other persons. The originating psychological

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situations can only be understood in terms of psychology, as total responses of the organism to its environment. The Concept of Psychosomatic Medicine: Conversion Hysteria, Organ Neurosis, and Psychogenic Organic Disturbance The application of these considerations to certain morbid processes of the body led gradually to a new chapter of medicine called "Psychosomatic Medicine." This expression maybe is not most fortunate, because it may imply a dichotomy between psyche and body (soma). If, however, we understand psychic phenomena as nothing but the subjective aspect of certain bodily (brain) processes, this dichotomy disappears. These psychosomatic studies in combination with psychoanalytic investigations meant an entirely new approach to the study of the causes of diseases. As has already been mentioned, the fact that acute emotions have an influence on body functions belongs to the most common everyday experience. To every emotional situation there corresponds a specific syndrome of physical changes, psychosomatic responses, such as laughter, weeping, blushing, changes in the heart rate, respiration, etc. Because, however, these psychomotor processes belong to our normal life and have no ill effects, medicine until recently paid little attention to their finer investigation. These changes in the body as reactions to acute emotions are of a passing nature. After the emotion disappears, the corresponding physiological processes, weeping or laughing or heart palpitation or elevation of blood pressure, also disappear and the body again returns to its equilibrium. The psychoanalytic study of neurotic patients revealed, however, that under the influence of permanent emotional disturbances, chronic disturbances of the body may develop. At first such chronic bodily changes under the influence of emotion were observed in hysterical patients. Freud introduced the concept of "conversion hysteria," in which bodily symptoms develop from chronic emotional conflicts. These changes were first observed in the muscles controlled by the will and in the field of sense perceptions. One of the most important discoveries of Freud was that whenever emotions cannot be expressed and relieved through normal channels through voluntary activity, they may become the source of chronic psychic or physical disorders. Whenever emotions on account of psychic conflicts become repressed, that is to say, become excluded from consciousness and thus from normal expression, they sustain a chronic tension which is the cause of the hysterical symptoms of the body.

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Also emotionally conditioned disturbances of the internal vegetative organs, which are not controlled by conscious voluntary impulses, such as the stomach or the heart, have been observed. Such observations came not from psychiatrists but from specialists in the field of internal diseases and led to the concept of "organ neurosis." Thi^ term is applied to disturbances of the internal vegetative organs caused by nerve impulses, the ultimate origin of which are emotional processes most probably localized in the cortical and subcortical centers of the brain. At first the neurotic or functional disturbances of the stomach, the bowels, and the cardiovascular system became well known under the name of gastric, intestinal, or cardiac neuroses. Another term often used for this type of disorder is "functional disturbance," referring to the fact that in such cases even the finest study of the tissues does not reveal any morphological changes discernible by the microscope. In such cases the anatomical structure of the organ is not changed ; only the coordination and the intensity of the organ-functions are disturbed. Such disturbances are considered as less serious because they are reversible, in contrast to those diseases in which the tissues show definite pathological alterations, often constituting irreversible damage. Since these functional disturbances are caused by emotional factors, psychotherapy thus gained a legitimate entrance into medicine proper and could not be restricted any longer exclusively to the field of psychiatry. The chronic emotional conflicts of the patient, the cause of the trouble, had to be eliminated by psychological treatment. Since these emotional conflicts arose during the life of the patient in his relationship with other human beings, the patient as a personality became an object of therapy. This is the avenue in which the emotional influence of the doctor upon the patient, medical art, gained entrance into scientific medicine and could not any longer be considered an appendage of therapy, so to speak a last artistic touch in the therapeutic activity of the physician, which in its essence was considered an entirely different, thoroughly scientific procedure. In these cases of organ neurosis, the emotional influence of the physician upon the patient became the main therapeutic factor. The significance of the psychotherapeutic function of the physician, however, at this phase of development, remained restricted to these functional cases, considered generally as milder disturbances, in contrast to the more serious genuine organic disorders based on permanent tissue changes. Of course in such organic cases the emotional state of the patient had for a long time been recognized as an important issue, yet a real causal connection between psychic factors and

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genuine organic disturbances had not generally been recognized. Gradually, however, it became more and more evident that nature does not know such strict distinctions as "functional" versus "organic." More and more clinicians began to suspect that functional disorders of long duration gradually may lead to serious genuine organic disorders based on visible anatomical changes. A few instances of this kind of disorder have been known for a long time. For example, the hyperactivity of the heart may lead to hypertrophy of the heart muscles, and the hysterical paralysis of a limb may lead, because of inactivity, to certain degenerative changes in the muscles. One had to reckon therefore with the possibility that a functional disturbance of long duration of any organ may lead finally to definite anatomical changes and to the clinical picture of severe organic illness. Intensive psychological and somatic studies of cases of peptic ulcers brought weighty evidence for the assumption that emotional conflicts of long duration may lead as a first step to a stomach neurosis which in time may result in an ulcer. There are also indications that emotional conflicts of another kind may cause continued fluctuations of the blood pressure which constitute an overtaxation of the vascular system. This functional phase of fluctuating blood pressure in time may cause organic vascular changes and, as an effect of these changes, a continued irreversible malignant form of hypertension. These observations have been crystallized in the concept of "psychogenic organic disorder." These disorders, according to this view, develop in two phases. The first phase consists of a functional disturbance of a vegetative organ, caused by a chronic emotional disturbance called psychoneurosis. In the second phase, the chronic functional disturbance leads in time gradually to irreversible tissue changes, to an organic disease. Progress in Etiological Thought This view of the causation of certain organic disorders means a remarkable change of traditional concepts. The traditional etiological view, as has been described before, was a localistic one essentially based on Virchow's cellular pathology. The symptoms of the disease were explained by morphological changes in the organs. As to the origin of these morphological changes, different factors have been generally accepted. For a long period after Pasteur's and Koch's discovery of pathogenic micro-organisms, the infectious origin of the pathological tissue changes was in the center of research. It was found that the specific diseases are caused by specific micro-organisms

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according to the point of their attack in the different parts of the body. In these cases the causal chain is : entrance of a specific microorganism into the body, dissemination of these organisms within the body through the blood and lymph circulation, and further development of the micro-organism in different parts of the body, destroying the normal structure and hence the normal functioning of the cells. This etiological theory could be validated through the experimental introduction of micro-organisms into animals, reproducing tissue changes similar to those observed in human beings. This one well-defined mechanism became soon the model for all etiological research. Apart from micro-organisms, other external factors have been discovered as responsible for certain tissue changes—factors such as mechanical, thermic, or chemical influences, the action of which, however, followed similar principles. For example, the inhalation of certain small dust particles by industrial workers and miners became another well-established etiological process. Another generally accepted pathogenic factor is the natural aging process of the organism, explaining such widespread disturbances as the sclerosis of the arteries in later life. In all these cases the symptoms of the disease are explained as the result of pathological tissue changes which can be traced back to certain external mechanical, chemical, or infectious factors or to the natural aging process. The significance of the new concepts of psychogenic organic disorders consists in the demonstration of a fundamentally different causation of disease. In these cases the pathological anatomical changes are the secondary results of disturbed function, and the disturbed function itself is the result of chronic emotional conflicts. If formerly every pathological function was explained as the result of pathological structure, now another causal sequence has been clearly recognized: pathological function as the cause of pathological structure. Although this etiological view is not entirely novel. vet if it is so explicitly formulated, many clinicians who were raised in the tradition of Virchow's principle and are still under the impressive influence of the simple and experimentally validated etiological discoveries of bacteriology are not inclined to accept it without reservations. Usually whenever a functional disorder is described, it is accepted with some doubt and the hope is expressed that further more precise histological studies will finally disclose tissue changes. The modern clinician is inclined to fall back upon the well-proved classical concept that disturbed function is the result of a changed morphological substratum.

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So, for example, Von Bergmann (2), who in 1913 still claimed that peptic ulcers are probably the results of a chronic gastric neurosis caused by emotional factors, fourteen years later felt the necessity to revise his views, return to a more conservative attitude, and recommend great reservation toward the diagnosis of an "organ neurosis" (3). He expressed his belief that in most such cases further research will disclose organic causes. Only slowly can this new concept overcome the traditional views, although it is not in the least contradictory to them. It only shows a different causal sequence in the development of certain diseases, changed function leading to tissue changes in contrast to the opposite sequence, when disturbed function is the result of structural changes. Previously the scientific credo in medicine was that further finer histological studies will reveal an anatomical basis for all so-called functional disturbances; today we feel, without questioning the soundness of this principle, that in many cases a thorough investigation of a life history might reveal the functional beginnings of truly organic disturbances. In these early phases, the disturbance of function has not produced as yet organic changes that are necessarily histologically discernible. The resistance against this concept is based on the erroneous dogma that disturbed function is always the result of disturbed structure and on the disregard of the opposite causal sequence. At present it is difficult to foresee what types of organic diseases follow this etiological scheme. It is most probable that, m the great chapter of medicine which might be called "Disorders of Unknown Origin," many will fall under this category. Some types of peptic ulcers and of essential hypertension probably belong to this group. Since the functions of the ductless glands are partially under psychic control (for example, the adrenal system is influenced by rage), it is probable that many endocrine disturbances will in the last analysis turn out to be the results of chronic emotional disturbances. This is clearly indicated in cases of toxic goiter, the beginning of which often can be traced back to emotional traumata. Furthermore, the influence of emotions on carbohydrate metabolism makes it possible that in the development of diabetes emotional factors may play an important causative role. Essentially this functional theory of organic disorders is nothing but the recognition, apart from external causative factors, of internal causes of diseases. In other words, many chronic disturbances are not caused by external, mechanical, chemical factors or by microorganisms, but by the continuous functional stress arising during the

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everyday life of the organism in its struggle for existence. All those emotional conflicts, which psychoanalysis has recognized at the basis of psychoneuroses and recently also as the ultimate cause of certain functional and organic disorders, arise during our daily life in the social contact with the environment. Continuous fears, aggressions, wishes, if repressed, result in permanent chronic emotional tensions, which disturb the functions of the vegetative organs. Many emotions resulting from the complications of our social life cannot be freely expressed and relieved, through voluntary activities, but remain repressed and then are diverted into wrong channels. Instead of being expressed in voluntary innervations, they influence the internal vegetative functions, such as digestion, respiration, or circulation. As countries thwarted in their external political ambitions often show as a result internal social upheavals, so also the human organism, if its normal relation to the external environment is disturbed, shows a disturbance of its internal politics, of its vegetative functions. There is much evidence to show that just as the pathological microorganisms are specific and have a specific affinity to certain organs, so also the emotional conflicts are different from each other and are liable in accordance with these differences to afflict different internal organs. Inhibited rage seems to have a specific relationship to the cardiovascular system; dependent help-seeking tendencies, as recent psychoanalytic studies show, seem to have a specific relationship to the functions of nutrition. Again a different and specific conflict between sexual wishes and dependent tendencies seems to have a specific influence upon respiratory disturbances. The increasing knowledge of the relations of emotions to normal and disturbed body functions requires that for the modern physician emotional conflicts should become just as real and tangible issues as visible microorganisms ( 1 ) . The main contribution of psychoanalysis to medicine was to add to the optical microscope a psychological microscope, a psychological technique by which the emotional life of the patients can be subjected to a detailed scrutiny. This psychological approach to the problems of life and disease brings the internal body processes into a synthetic unit with the individual's external relations to his social environment. It gives a scientific basis to such empirical everyday observations as that a patient often shows marvelous recovery if he is removed from his family environment or if he interrupts his everyday occupation and thus is relieved from those emotional conflicts which arise from family life or professional activity. The detailed knowledge of the relation of emotional life and body processes extends the function of the physi-

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cian: the physical and mental care of the patient can again be united in one hand. The division of the healing profession between religion and medicine (the "lay analyst" is the last residue of this division) has been an artificial division based on insufficient knowledge of the functions of the body and personality in their mutual interrelation. REFERENCES 1. ALEXANDER, F., and FRENCH, T. M. Studies in Psychosomatic Medicine. New York: The Ronald Press Co., 1948. 2. BERGMANX, G. VON. Ulcus duodeni und vegetatives Nervensystem. Bcr. klin. Wschr., 1913, 50. 3. . Zum Abbau der Organ Neurosen als Folge interner Diagnostik. Dtsch. mcd. JVschr., Leipzig, 1927, 53, 49. 4. GREGG, A. The future of medicine. Harv. Mcd. Alumni Bull., 1936, Oct. 5. WHITE, W. A. The meaning of disease. Baltimore: The Williams & Wilkins Co., 1926. Pp. 38-40. 6. ZWEIG, STEFAN. Die Hcilung durch den Gcist ("Mental Healers"). Leipzig: Insul-Verlag, 1932.

Chapter 3 THEORETICAL SCHOOLS OF PSYCHOLOGY By ALBERT ELLIS, Ph.D.

What Psychology Is PSYCHOLOGY, as any textbook or dictionary will tell you, is the study of human behavior . . . or the human mind . . . or consciousness . . . or the human organism . . . or interpersonal relationships . . . or human nature. And so it is. At the same time, as many texts will inform you, anthropology, sociology, biology, psychiatry, sociometry, education, and perhaps a dozen other new and older sciences—these, too, are the study of human behavior, mind, consciousness, nature, interpersonal relations, or what you will. And so they are. What, then, is psychology ? Psychology, frankly, is practically anything you wish to make it. In the last analysis, it consists of whatever a particular writer—you, I. or anyone else—wants to define it as. For whatever this writer's specific definition of psychology is, you may be quite certain that, on historical, theoretical, and practical grounds, he will be able to find sufficient justification for it. Psychology, from Aristotle's day (384222 B.C.) to the present, has included almost everything you might conceive of; and today, when psychologists are newly applying their theories and findings to areas like war, politics, international affairs, labor-management relations, airplane design, economic surveys, and what not, drawing the line between what is a valid psychological application and what is not is like neatly demarcating where biology and chemistry each end and where biochemistry begins. Maybe, to be honest about the matter, we had better realistically say that psychology is but one ill-defined, vague, overlapping aspect of the broad generality of human sciences, ranging from astrophysics to speculative philosophy, and let it go at that. More practically, we may state that psychology is what psychologists generally think about and practice; and, even then, we must be y ery careful to use the plural, psychologist?, and never the singular, a psychologist. For modern psychologists need no more study and

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practice the same things than need, let us say, different kinds of medical specialists or different kinds of biologists. Sometimes, for example, a clinical psychologist knows just about as much about the psychological work being done at the psychoacoustical laboratory at Harvard or the airplane design work being carried on by psychologists working with the Armed Forces (and vice versa!) as the average bookkeeper in a small office knows about the electronic accounting methods of huge corporations. What Psychologists Do Psychology, then, is what psychologists think about and do. At the present time, if we are to go by the main headings employed in the latest issue of Psychological Abstracts,1 modern psychologists largely study and work at the following types of things : 1. Psychologists build theories and systems of psychology. They take the findings of many different workers (psychologists and others) in numerous fields of research and from these construct systematized theories of human behavior which presumably explain how human beings generally perceive, think, feel, and act; and why, at certain times, they see, think, feel, and act in specific kinds of ways. 2. Psychologists devise experimental methods and apparatus. They try to determine what are the best ways of discovering how humans (and animals) see, think, feel, and act, and what techniques and equipment are best designed for use in controlled human and animal experiments. 3. Psychologists devise and apply all kinds of tests for determining how well human beings think, what is their personality structure, how much they have learned, what are their interests, what are their abilities, how handicapped are their senses, and so on. 4. Psychologists devise and use statistical methods which will best enable them (and other scientists) to determine whether a given group or individual differs significantly from, or shows significant relationships to, other groups or individuals in certain stipulated ways. 5. Psychologists investigate the psychophysiological functions oi human (and other) organisms, with especial reference to their nervous systems and their receptive, perceptual, and response processes (e.g., vision, audition, taste, smell, touch, and the kinesthetic senses). 1 Psychological Abstracts is published monthly by the American Psychological Association and contains abstracts of the current psychological and allied literature.

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6. Psychologists study the complex processes and organizations of humans and other living creatures, including their learning and memory, thinking and imagination, intelligence, personality, and esthetic sensibilities. 7. Psychologists particularly investigate and try to apply themselves to the solution of the problems inherent in the growth and development of human beings, including their infancy, childhood, adolescence, maturity, and old age. 8. Psychologists concern themselves with the group or social behavior of human beings, with their cultures and cultural relations, with their social institutions (family, government, economic groupings, etc.), and with their language and communication. 9. Psychologists diagnose and treat individuals who get into trouble with themselves and/or their society. They do diagnostic interviewing and testing, especially the administration, scoring, and interpretation of intelligence tests and of projective and nonprojective techniques of personality evaluation. They treat all types of maladjusted individuals, with special emphasis (at present) on child guidance and on work with neurotic adults and with something of a de-emphasis on the treatment of psychotics. They employ all types of psychotherapy, from nondirective techniques to intensive psychoanalytic procedures, but they have little or nothing to do with physical methods of treating mentally disturbed individuals. 10. Psychologists specialize in the vocational guidance of individuals who are having some difficulty with job selection, training, or placement. 11. Psychologists conduct investigations of and try to determine the best techniques of handling individuals with all kinds of behavior deviations, including mental deficiency, sexual disorders, behavior problems, speech disorders, delinquent and criminal activities, clinical neurological problems, psychoneuroses, psychosomatic problems, psychoses, and physical handicaps. 12. Psychologists intensively study and apply themselves to the possible solution of many educational problems, such as those of school learning; the measurement of interests, attitudes, and habits; special education; educational guidance; educational measurement; and the selection of educational staff personnel. 13. Psychologists concern themselves with many personnel problems, such as the selection and placement of employees and labormanagement relations. 14. Psychologists are often active in industrial, commercial and other economic affairs, including the making of time-and-motion

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studies, the design of industrial equipment, office and factory efficiency, and professional affairs. It can be seen, in sum, that psychologists have a finger in almost every possible kind of pie; and that, to call oneself a psychologist, in the present day and age, might mean almost anything. That is why there is really no such thing as a psychologist; only psychologists. Some psychologists work most closely with associates wTho may call themselves physiologists, efficiency experts, psychiatrists, educators, personnel managers, sociologists, pediatricians, anthropologists, marriage counselors, statisticians, or heaven knows what else. Which merely means, of course, not that psychologists are more peculiar or amorphous than other contemporary scientists, but that modern science no longer consists of individualized, rigidly separated, nicely categorized, and finely demarcated fields of research and application. Rather, virtually all theoretical and applied scientists who are in any way worth their salt are, in this atomic age, continually encroaching upon the areas of, using the findings of, working side by side writh, and becoming inextricably confused with other scientists who, technically, have titles which seem to be very different from theirs. This modern interrelationship and interdependency among the major scientific fields is, if anything, a healthy sign, and one which seems to show that the original arbitrary dividing lines between one so-called scientific discipline and another were figments of ignorance and (sometimes) professional jealousy more than anything else. Today, with almost every new scientific advance, it begins to appear more and more as if there are no individual, artificially categorized sciences; but, rather, that there is one massive body of scientific knowiedge, almost impossible to separate, to which all the so-called individualized sciences endow substance, and to which none has a truly unique, unintegrated, nonoverlapping contribution to make. Psychology, which wras perhaps once a single, easy-to-define discipline, has now become a much-split body of theory and applied procedure that has no realistic existence except in so far as it draws from and gives to almost every other existing major scientific discipline; and the same, in turn, may be said of each of these other areas, which today are absolutely nonself-sufficient and are nonuniquely contributing to human knowledge. Antecedents of Psychology According to the standard psychological textbooks, there are several so-called schools of psychology, such as introspective psychology, functionalism, connectionism, behaviorism, conditioning, field theory.

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and dynamic psychology. Some of these "schools," however, are almost extinct already (who, for example, today calls himself an introspectionist or a functionalist?) ; and others, where they have any meaning at all, have it mainly for specific areas of psychology—such as perception or learning—and by no means for all or most of its theoretical or applied aspects. Connectionism, for example, is still sometimes discussed as a possible explanation of why rats or human beings learn to solve problems, after a certain number of trials, with fewer errors and in a shorter period of time. So far, however, it has had relatively little place in the findings or applications of child psychologists, personnel people, clinical psychologists, industrial consultants, or social psychologists. As a "school," it probably never seriously influenced the work of any but a small minority of psychologists (aside from lectures which they may have given in general or educational psychology courses). Similarly, even when they were at the height of their popularity, most "schools" of psychology seem to have been influential largely in the making of psychological examination questions, and relatively little in actual psychological applications. While standard psychological texts stop at this point to say at least a few words over the graves of Fechner (1801-87), Wundt, (1832-1920), James (1842-1910), Angell (1869-1949), Titchener (1867-1927), McDougall (1871-1938), and other early psychological giants, it would seem better, considering the actual influence they now wield over modern psychological thought, to let them rest in peace. Great figures though they once indubitably were, and important as has undoubtedly been their developmental influence over psychology, adherents to their basic concepts are today few and far between; and there is too much of current import in psychological theory and practice for the student to be unnecessarily burdened by their birth and death notices. More to the point, perhaps, might be a brief discussion of those few contemporary "schools" of psychology which still exert considerable influence over the minds and acts of contemporary psychological theoreticians and practitioners. Of these, three seem to stand out most prominently: namely, conditioning, field theory, and dynamicpsychoanalytic psychology.

Conditioning and Behaviorism The psychological principles of conditioning originated largely in the laboratory of Pavlov (1849-1936) in Moscow during the early years of the twentieth century, and were extended and popularized

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in America by Watson (1879), Dunlap (1875-1949), Hilgard (1904), Marquis (1908), and many others (7). In their extreme Watsonian form, called behaviorism, they led to the doctrine that, since it is hardly possible for psychologists to study consciousness directly, they should study only overt behavior and should derive all psychological laws from their study of this behavior alone. While the conditionists and behaviorists were having their psychological heyday, Thorndike (1874-1949) was simultaneously developing a stimulus-response, connectionist theory of human and animal learning which in some ways used the findings of conditioned reflex psychology and in some ways went beyond these. Thorndike and his pupils emphasized neurological connections between the effects of a stimulus on an organism and the response of this organism to the stimulus, and they posited the discovery of several "laws" of learning, such as the law of effect, the law of recency, the law of identical elements, and so on (15, 25). Conditioning and connectionist psychology had both seemed to become somewhat outmoded and were almost on the way to being obscured by field theory and dynamic-psychoanalytic psychology when, in the late 1930's, Clark L. Hull (1884-1952) and his associates at Yale University revived them with new vigor; so that, recently, the psychological literature has been almost surfeited with papers trying to prove or disprove the "principles of behavior" set down in Hull's challenging text of 1943 (10). What Hull essentially has done in this and succeeding works is to take Thorndike's law of effect and, by solidly linking it with (a) Pavlov's principle of reinforcement, (b) Darwin's (1809-82) and Freud's (1856-1939) notions of organismic need, and (c) highly involved statistical procedures and formulas, to deduce the most specific kind of laws of habit formation and learning that have yet come out of psychological laboratories. Hull's main hypothesis is that if an organism tries in various ways to satisfy one of its basic needs and finally succeeds in doing so, the "random act, or combination of acts, which chanced to eliminate the need should on subsequent occasions acquire an increased tendency to dominance over the other acts which did not lead to a reduction in the need." Such a strengthening or reinforcement constitutes learning and results in habit formation. Gestalt or Field Theory Psychology Gestalt or field theory psychology, which bitterly opposed the early conditioning psychology of Pavlov and Watson, today still remains

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something of an active "school," with many devoted adherents (13). Its main spokesmen have been Wertheimer (1880-1943), Kohler (1887), Koffka (1886-1941), and Lewin (1890-1947), and its main contentions seem to be : (a) that an atomistic way of looking at the individual parts of human behavior, instead of that behavior as a whole, produces misleading psychological principles; (&) that objects in a given field of observation continually interact with and influence each other and cannot be truly seen or comprehended in, of, or by themselves; (c) that individuals do not learn by simple connections, or trial-and-error learning, but by grasping things as a whole, and gaining sudden insight into problems and tasks; (d) that learning is purposive and depends upon the motivations, desires, and goals of the learner rather than his passive participation in any acts or events.

Dynamic-Psychoanalytic Psychology Dynamic-psychoanalytic psychology, stemming from the work of Sigmund Freud and his early associates (3, 4, 5), is now the third major psychological "system" which dominates modern thought and application in psychology. We shall discuss it at length in our next section, since it is that part of psychology which is most closely related to medical science. What should be emphasized here is that, no matter what its influence or how many its adherents, no psychological school of thought today stands by itself as distinct from all other schools; but all, instead, are making their contributions to the main stream of psychological thinking and are, to some degree or other, accepted by virtually all modern psychologists. Hull, for example, has accepted some of the Freudian concepts of organismic need in his theorizing and has liberally sprinkled his principles with terms like "stimulus compound," "afferent interaction," and other Gestalt-like terminology. And the dynamic-psychoanalytic psychologists make considerable use of the holistic ideas and the interactive processes of the advocates of field theory: who, in turn, especially in the work of Lewin and his associates, make much use of the concepts of needs, presses, frustration, and so forth, first emphasized in psychoanalytic thinking. All told, then, the functioning of specific schools of psychology in any autonomous way is, today, a mythological concept to which only a few old die-hards subscribe. The main problem of the present era is no longer the integration and interrelationship of different schools of psychological thought but the interrelating of psychological theory as a whole with various

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other theories derived from other basic social sciences, such as sociology, anthropology, economics, and political science. And, impelled by this necessity, cross-discipline thinking in the social (and, to some extent, social and physical) sciences is nowadays becoming so commonplace as to make internecine squabbles among different "schools" of psychological thought seem of only historical import. Psychology and Medicine The application of psychology to medicine goes back a long way: to the earliest forms of witchcraft, sorcery, and voodooism, which for many centuries have been employed to effect cures, not merely of psychological illnesses but of organic states as well (16). In modern times, psychological attempts at curing human ailments descend from Anton Mesmer (1734-1815), who in the middle of the eighteenth century began to employ "animal magnetism" or "Mesmerism" (to which we refer today as hypnotism) in the treatment of various ailments. Mesmer was followed by Braid (1795-1861), Liebeault (1823-1904), Bernheim (1840-1919), Forel (1848-1931), and other physicians of the nineteenth century, who used hypnotic trances in therapeutic ways. Finally, hypnotism was brought to its greatest heights as a medical force in the investigations and treatments of Jean Martin Charcot (1825-93) and Pierre Janet (1859-1947), who performed one curative miracle after another with its use, and who devised theories to explain neurotic hysterical behavior as being caused by what we would today call unconscious emotional conflicts. Freud's Psychodynamic-Psychoanalytic Theory The real founder of modern dynamic psychology, however, was one of Charcot's pupils, the Viennese physician Sigmund Freud. While hardly the discoverer of unconscious mental processes— Herbart (1776-1841), H6ffding (1843-1931), and other psychologists had spoken about them many years before he did—Freud seems to have been the first to use them systematically in the treatment of mental disorders and the first to construct around them an entire system of dynamic psychology which has, up to the present day, undoubtedly wielded the greatest of all influences in clinical and medical psychology and has also had wide-ranging effect in numerous other social sciences. To summarize Freud's basic tenets in a page or two is a thankless and virtually impossible task; but let us take a stab at it anyway.

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The fundamental assumptions of psychoanalysis as Freud finally postulated them seem to be as follows:

Instincts, Ego, Id, Superego.—1. Human beings are born with desires and instincts, especially the life or erogenous instincts on the one hand and the destructive or death instincts on the other hand, which exert a constant pressure on the individual to express themselves in satisfying ways. 2. The human instincts and the energies or driving forces which accompany them are normally held in line by a series of checks, balances, and counterbalances—defenses, resistances, and dynamisms— which are an intrinsic part of the normal human personality. The personality itself is divided into three important compartments : a) The ego is the well-organized, relatively well-controlled, and largely conscious part of the personality. It is essentially logical or rational in purpose, and it continually tries to preserve the proper functioning of the personality under the stresses and strains of normal social living. b) The id is the rather disorganized, more primitive, irrational aspect of the personality which serves as a reservoir for sexual, destructive, amoral, and other human instincts which are incessantly seething within it, and seeking for some outward expression. The id and its contents are entirely unconscious. c) The superego is that part of the ego which identifies itself with the dictates of an individual's parents and of society as a whole and which consequently acts as a kind of conscience to the ego and helps regulate and censor its impulses. Psychosexual Development.—3. The human infant normally goes through various stages of his psychosexual development: (a) In the stage of oral eroticism, sucking, biting, and incorporating impulses give primary sexual satisfactions and exert a tremendous influence on infantile behavior, (b) In the anal-sadistic stage, the desire to master and destroy outside objects is first prominent, followed by a desire to cherish and hoard objects so that they cannot get away from one's mastery over them, (c) In the phallic stage, the genitals themselves become the prime source of children's libidinal satisfactions, (d) Because of the incestuous desires of the child toward his opposite-sex parent during the phallic stage and because of the impossibility of his satisfying these desires (in our society) and his guilt over having them, the Oedipus complex (Electra in the girl) stage arises, and the child begins to repress his sexual desires—to throw them back into his unconscious mind and to refuse to remain

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aware of them, (e) The repression of these sex urges results in the latency period, when the child sublimates his sexuality into other channels, including homoerotic attachments toward members of his own sex. (/) Puberty finally intervenes, bringing with it an upsurge in sexual energies which break through the repressions of the latency period and carry the child into the turmoils of adolescence and, eventually, into adult sexuality. Mental Dynamisms.—4. The human personality, in our culture, is a mass of conflicting desires; so that the ego, id, and superego are continually at war with each other. Normally, the ego erects clever defenses, so that the demands which the id and superego make on it do not become too painful. Thus, the individual resorts to such dynamisms as these: When things become too difficult for him, he runs away or regresses to an earlier, more infantile mode of adjusting. When he feels weak himself, he identifies with stronger, more powerful individuals and takes refuge in allying himself w7ith their stronger individualities. When overcome with unpleasant feelings of guilt, anxiety, or terror, he displaces or projects them onto other individuals or things. When unable to carry out the demands of his instincts, he sometimes sublinates them into socially acceptable channels instead of overtly expressing them in forbidden ways. When incapable of doing what he wants to do to gain prestige and love, he frequently compensates by doing something else which will gain him recognition. When blamed for something which he feels that he should not have done, he rationalizes his actions and thus excuses himself. In these and other ways, said Freud and his early disciples, the individual defends himself against his own conflicting instincts, guilts, anxieties, and fears. Neurotic Symptom Formation.—5. When an individual has come successfully through his Oedipal and other childhood stages, and can consciously face his main adult conflicts, these can usually be resolved without too much harm to his psyche. When, however, he has a personality structure that has been weakened or fixated on an infantile level and wrhen he has to resort continually to repressing his basic conflicts and throwing them back into his unconscious mind, the individual's psyche becomes overwhelmed or flooded with affect that it cannot adequately handle; and some of this repressed affect becomes so strong that it tends to return to consciousness, to the great embarrassment and discomfort of the individual. At this time, neurotic symptom formation must be resorted to in order to prevent this repressed material from becoming conscious again. Neurotic

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symptoms may take many different forms—e.g., compulsions, obsessions, phobias, psychosomatic illnesses, conversion hysterias, anxiety states, etc. Basically, they all arise when the individual is no longer able to encompass the painful stimuli that impinge on him, or to keep repressing successfully the conflicts between his ego and superego, his ego and id, or his id and superego. Freudian Psychoanalytic Treatment.—6. At this point, psychoanalytic treatment may be employed to bring the individual's unconscious conflicts to consciousness, to unmask and work through his symptoms and his defense mechanisms, and to enable him to understand himself and face himself more effectively, so that his ego becomes relatively stronger and his id and superego lose some of their power over his activities and feelings. Psychoanalytic treatment proceeds : (a) by getting to the bottom of the patient's unconscious desires and defenses through techniques of free association, dream analysis, uncovering of childhood memories, etc.; (b) by leading to the creation of an emotional relationship between the analyst and analysand (transference) which enables the analysand to relive some of his earliest family feelings and conflicts with the analyst; and (c) by interpreting to the patient, on the basis of the material arrived at in the free associations, dream analyses, transference feelings, and other aspects of the analytic procedure, what his defenses are, how they were originally constructed, how they are continually influencing him, what neurotic gains he is achieving through employing them, how he is resisting giving them up, and how they are instrumental in producing his basic character structure and the specific symptoms of his neurosis. This, all too briefly exposited, is the framework of psychoanalytic theory raised by Sigmund Freud. Since its origins in the last decade of the nineteenth century, it has been vigorously carried on and modified by various neo-Freudians (3, 24), some of whose contributions we shall now discuss. Alfred Adler Alfred Adler (1870-1937) was one of the first of Freud's early disciples to break with the master and to set up a theory and a practice of psychotherapy which was in parts quite un-Freudian (1). The essentials of Adler's differences with Freud seem to be these: (a) Adler stressed organ inferiority and insisted that children born with physical inadequacies tended to compensate strongly for these inadequacies in some other way; but often, failing to do so, suffered

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inferiority feelings which led to neurotic symptoms, (b) Aside from organ inferiorities, Adler held that human beings are born with deepseated feelings of inferiority which keep pressing them on to master themselves and the world; and which, when they meet insuperable objects, frequently throw them into despair, anxiety, and neurosis, (c) To overcome these feelings of inadequacy, the individual has to move purposively, early in life, toward a certain life goal, and to mold his whole character around the achieving of this goal. If he is a man, in our society, he usually strives for success; and if she is a woman, she may unconsciously exert a "masculine protest"—a rebelliousness against woman's subsidiary role in our culture and an attempt to surmount it by unconsciously acting in masculine ways, (d) Sex drives, Adler held, are of undoubted importance in human life; but they are normally subordinated to other drives: to the attainment of the life goal or to the achievement of social esteem, vocational success, or love, (e) Therapy, according to Adler, consists of showing an individual what his realistic life goals should be, and getting him to give up his unrealistic and often antisocial strivings. He must be made to accept social feeling and responsibility; and he can, presumably, be helped to do so in a relatively short period of therapy and without recourse to the Freudian techniques of free association, dream analysis, and the detailed working through of early Oedipal relationships.

Carl Jung Carl Jung (1875), another early pupil of Freud's, soon broke away from orthodox Freudianism and set up a complicated psychological system of his own (11, 12). The essentials of Jungianism appear to be these: (a) The libidinal instincts are basic to all other instincts, and constitute the fundamental energy processes of life. Libidinal energies are considered to be far broader, however, than specific sexual urges. (6) Symbols are most important in life, since through symbolizations (myths, fantasies, dreams, etc.) excess libidinal energy finds an outlet. Symbols do not merely tell you something about the patient's past life, but signify the way in which he will approach the future, (c) Man has not only a personal unconscious mind, but a collective unconscious wThich he inherits from his ancestors, and which contains representations going back even to his animal ancestry. Men all over the world act in similar ways and have identical symbols because of the representations or archetypes in their collective unconscious minds, (d) There are four basic types of human perception: thinking, feeling, sensing, and intuition. In

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each of or all these four modes of dealing with the inner and outside stimuli, individuals may be extroverted (oriented toward outward things), introverted (oriented toward their own psyches), or ambiverted. (e) Therapy consists of revealing to a patient the depths of his own individual and collective unconscious feelings, so that he may draw from the wisdom of the unconscious and may come to accept a broad religious outlook.

Otto Rank Otto Rank (1884-1939) started off as an arch-disciple of Freud and later became something of an arch-enemy (17). He was one of the first analytic thinkers to take broad excursions into the questionably scientific jungles of metapsychology, wherefrom he brought out (sometimes more dead than alive) brilliant theories of mythology and art which have served as prototypes for a succession of semimystical formulations that have been plaguing psychoanalytic literature ever since. Not content with these dubious contributions to analysis, Rank went on to construct an entire system of dynamic psychology which blends crackpotism and incisive observation almost indistinguishably. Rank is mainly noted for doctrines such as these: (a) Birth, Rank held, is a painful, traumatic experience to the neonate, who, for the rest of his life, tries to get back into the warm comfort of the womb or some symbolic representation of it. (b) The normal child gradually gets rid of his primal, birth-caused anxiety, but the exceptional child who does not do so becomes neurotic, (c) The will of the individual himself is as important as his objective environment; and truth, in fact, is determined subjectively by the individual's will, (d) The neurotic individual, on the one hand, and the creative genius, on the other, both refuse to accept the everyday truth that ordinary individuals accept; and they create, in its stead, their own truth. But the neurotic is not creative enough to do without everyday illusions and hence fails to make a good adjustment to his society, (e) Therapy should be mediated largely through the relationship between the therapist and the patient, and not through an unraveling of the patient's past life and complexes. The patient must be enabled to accept himself with all his conflicts and ambivalences and to accept the reality that he himself creatively sets up. Other Neo-Freudians While Rank was constructing his quasi-psychoanalytic doctrines, other neo-Freudians were usually sticking closer to the precepts of

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the master and generally managing to remain sufficiently orthodox not to suffer the fate of expulsion from the international psychoanalytic society of the orthodox Freudians. Ferenczi (1873-1933), for example, advocated a more active type of psychoanalysis than the usual passive Freudian techniques indicated. Stekel (22) concentrated heavily on the sexual aspects of neurotic disorders and experimented with brief analytic methods which foreshadowed some of the later work of Franz Alexander (1891) and the Chicago group of psychoanalysts. Alexander and Thomas M. French (1892), along with Flanders Dunbar (1902) and many other analysts, pioneered in researches in psychosomatic medicine. Lawrence Kubie (1896) became one of the first leading analysts to attempt to put psychoanalytic theories to objective, scientifically controlled laboratory experiments. Wilhelm Reich (1897), who originally made some major socioeconomic and cultural contributions to psychoanalysis, later went most unorthodoxly into vegetotherapy, orgone accumulators, the so-called cancer biopathy, and wrhat not, and now espouses a viewpoint that virtually all psychoanalysts (and other scientists) consider to be buncombe (18). Theodor Reik (1888), who has remained more Freudian than most other leading analytic writers, has recently emphasized the intuitive aspects of analytic therapy in such a way as to border on the magical and mystical rather than the scientific aspects of analysis (19). Karen Horney Karen Horney (1885) has, to date, probably been the bestknown critic of orthodox Freudianism to gain a wide following, with Erich Fromm and Harry Stack Sullivan (1892-1949) coming closely on her heels. The essentials of the Horneyan position (8, 9) seem to be these: (a) Virtually all civilized Western men and women have some neurotic trends; but the real neurotic is a rigid and inflexible person whose trends get to wield such a power over his whole personality structure that he cannot perform adequately or realize his own potentialities, (b) Cultural factors play an important part in causing neurotic trends and neuroses, while Freudian-espoused instincts are not by any means as important as analysts used to consider them, (c) Anxiety is basic to neurosis; and when normal defenses against anxiety fail, neurosis erupts. Basic human anxiety arises out of childhood insecurity, mainly over the child's sense of not being adequately loved and accepted, (d) People in our culture try to overcome their anxiety by trying to master others, by submitting to

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them, or by running away from them, (e) Individuals build up idealized, unrealistic images of themselves which make them liable to all kinds of hurts and disillusionments and force them to keep using up their energies to sustain their idealized self-portraits. (/) Psychoanalytic therapy should stress: (1) the present problems of analysand, rather than his childhood problems;

(2) the general conflicts of the patient, rather than his specific sex conflicts; (3) a complete character analysis, rather than a mere trying to rid the patient of his symptoms; (4) the patient's acceptance of a socialized, moral viewpoint. Erich Fromm Erich Fromm's (1900) modern espousal of psychoanalytic viewpoints can hardly be distinguished from Karen Horney's in several respects, especially in its emphasis on cultural rather than instinctual factors in the production of neurosis, and its tendency to de-emphasize the sex factors which orthodox Freudians tend strongly to uphold (6). Fromm notably concerns himself, however, with the problem of political authoritarianism; and he points out that when people are basically insecure, when they do not accept and love themselves sufficiently, it is very easy for them to surrender themselves to irrational authority and to kowtow to demagogues and dictators. Fromm's viewpoint, like Horney's, also stresses a social-moral-religious element; but Fromm seems to define morality and virtue in terms of productive creativity and individual expressivity, while Horney's views seem to be basically more conventional and conformist. Harry Stack Sullivan The latest—and most difficult to understand—white hope of modern neo-Freudianism seems to be the late Harry Stack Sullivan (14, 23), whose active disciples are rapidly growing in American psychoanalytic practice. Sullivan, because of his unique terminology, at first blush appears to be quite different from, and even opposed to, orthodox Freudianism; but when translated into simpler terms, this difference often turns out to be more apparent than real. He does, however, have several unique contributions to make to dynamic psychological thought and practice, chief of which seem to be these: (a) Men and women normally have an inherent drive toward good adjust-

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ment, mental health, and personality integration, and this drive can be effectively utilized when they for the moment go into neurotic dives, (b) The core of human personality organization is the individual's self-concept, which he originally derives from the concept that his parents and other early associates have of him and that he uses, in turn, to help him formulate his concepts of these parents and associates, as well as of later persons in his environment, (c) Personality, consequently, is largely a product of the interpersonal relations of an individual with the other individuals in his environment; and one's self becomes good, bad, or indifferent in direct relation to the kind and quality of the interpersonal relationships one has with others. (d) Once the self is formed, it becomes the integrative core of the personality structure, and it employs various dynamisms and defenses—such as the feeling of anxiety—to help itself deal with and order the world and the people and situations that it encounters. (e) Individuals with lowered self-esteem or poor self-concepts tend to be overwhelmed by anxiety and to develop various neurotic or psychotic symptoms, (f) These symptoms can only be unraveled, interpreted, understood, and forgone by an intensive analytic process which includes: (1) an analysis of the patient and his past interpersonal relationships ; (2) an analysis of the patient's present interpersonal relationships, especially including those with the analyst; (3) an analysis of the analyst's interpersonal relationships, past and present, especially his present ones with the patient. Rogers' Nondirective Therapy One more system of dynamic psychology requires mentioning here, even though it is often conceived of as being antipsychoanalytic in origin and design : and that is the nondirective therapy of Carl Rogers (1902) and his associates (20). Actually, this method is a derivative of the work of Otto Rank, Jessie Taft (1882), Frederick Allen (1890), and other relationship therapists who followed, though in a somewhat zigzag line, modifications of the original Freudian analytic methods. Rogers, however, has taken the Rankian therapeutic techniques to extreme forms; and, along with his techniques of psychotherapy, he has evolved some theoretical formulations which are, though couched in nonanalytical terms, essentially derived from psychoanalytic theories. The main essentials of the Rogerian viewpoint seem to be as

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follows: (a) The client is assumed to be an essentially healthy, potentially well-integrated individual who has the capacity to snap out of his current difficulties if only he is given a chance to express his feelings about them adequately, (b) The main cause of the client's difficulties is seen not as anything which has really happened to him, but as his perception of himself and of what has happened to him; and it is assumed that, once he perceives himself differently through contact with the therapist, he w7ill almost automatically forgo his symptoms of maladjustment, (c) The technique of getting the client to perceive himself in a different and less disabling light consists largely of: (1) accepting him fully, in a noncritical manner ;

(2) encouraging him freely to express himself and especially to give vent to his feelings about what is bothering him, rather than mere description of events or ideas; (3) under no circumstances advising or inducing him to do anything, but always reflecting his own feelings and allowing him to make his own decisions; (4) under no condition trying to diagnose what is wrong with him or interpreting to him what may be bothering him ; (5) generally tackling his current problems and feelings and never trying to probe back into their origins in his past life. While dynamic-psychoanalytic psychological thinking of the past fifty years has made most significant and important contributions to psychology and medicine, it has often been done, up to the present time, on an essentially nonscientific, catch-as-catch-can basis. To see how scientific psychology may be utilized effectively by dynamic psychology, we shall now briefly examine some of the basic elements of scientific method as applied to psychological thought and practice. Psychology and Scientific Method The general principles of scientific method may be stated somewhat along the following lines (2) : 1. Scientific method is not one specific set of rules which must be followed dogmatically by all scientists, but is, instead, a way of looking at things in an impartial, objective, unprejudiced manner. 2. Quantification and controlled experimentation are not absolutely necessary to scientific method, but they offer a distinct safeguard to it and should be employed wherever feasible. 3. Complete impartiality and objectivity are hardly possible to any scientist (or other human being), and it is unrealistic to expect

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them to be. Scientists should strive, however, to be as impartial and objective as they realistically can be—and, at least, to face, analyze, and understand the prejudices that they do have. 4. There is no rest, no absolute Truth, for the scientist. Science continually discovers new facts and in the light of these discoveries changes its old hypotheses and theories. 5. The main steps in scientific investigation usually consist of: (a) preliminary analysis of the problems to be investigated; (b) the forming of hypotheses to be tested; (c) the testing of these hypotheses by controlled experiments or other valid methods of gathering data; and (d) making adequate generalizations from the information obtained. If possible, all investigations and experiments should be designed so that there is some way for later investigators to repeat them and check their findings. 6. Social and psychological scientists must be aware of the dangers of overmechanizing their investigations and limiting themselves in their experiments to the principles and practices which mainly apply to the physical sciences. 7. "Hunches" and "intuitions" may be of great value in the formulation of scientific problems and hypotheses, but at the same time rigorous verification of all scientific "hunches" and "intuitions" is a prime requisite for the establishment of a scientific discipline. 8. In the last analysis, all sciences rest on observed facts; and as soon as any body of knowledge begins to deal with pure speculations, theories, or creeds which cannot possibly be empirically substantiated, then it may well be a legitimate field for human thought or endeavor —but it is not science. 9. In general, William of Occam's (1280-1349) Razor—which states that the explanation that involves the fewest or simplest assumptions is preferable—should be adhered to; though, in sciences like dynamic psychology, it may occasionally be forgone, since sometimes the more complex explanation for a human act, wish, thought, or feeling is more accurate than a simpler one. Floyd Allport's (1890) dictum, however, is to be kept strongly in mind : namely, that abstractions of a higher order are suspect unless the steps by which the abstraction emerges from the observed data, and by which it is limited, can be set forth plainly. 10. There is nothing sacrosanct about the physical, as differentiated from the social sciences; and both have, at present, all too many inherent difficulties and limitations. But just because the social sciences at present involve a high degree of indeterminacy, the difficulty of controlling variables adequately, the cultural prejudices of the ex-

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perimenter, and the like, social scientists must try especially hard to employ scientific methods, instead of throwing up their hands in despair and flirting with unsystematized or metaphysical procedures. The foregoing methods of science have been, in the main, fairly closely followed by psychological researchers of the past half-century. Psychoanalytic writers and practitioners, however, have frequently deviated from them. They have, for example, often set up vague, indefinable hypotheses (like that of many individuals having an "oralerotic" or "anal-sadistic" character) which are virtually impossible either to substantiate or destroy on empirical grounds. They have compartmentalized the human personality into various subsections (e.g., ego, id, and superego) which have taken on demonologized, mythical existences of their own. They have made vast and meaningless overgeneralizations from a great paucity of scientifically observed facts. They have allowed their own personal feelings and biases to influence their formulations. They have deified and bowed down nauseatingly to dubious psychoanalytic gods. They have employed piteously small, nonrandomly selected, and peculiar samples of subjects from whose activities to deduce general laws of normal and abnormal behavior. They have gone, scientifically unprepared, into vast areas (art, literature, anthropology, politics, etc.) where they have had no basic training and have made rash, speculative judgments therein. They have compounded tenuous hypothesis upon hypothesis, without seeking for observable facts with which to verify any of them. And so forth (2, 21). Dynamic-psychoanalytic psychology, therefore, has much to learn from those psychologists who have for many years disciplined themselves to a closer working relationship with scientific method—just as these other psychologists, in turn, have much to learn from the brilliant theorizing and clinical insight of the dynamic psychologists. It is to be hoped that the last fifty years of our century will see a proper welding of scientific and dynamic psychology that will be of inestimable value to both and that will result—at long last—in the establishment of the science of personality evaluation and psychotherapy.

REFERENCES 1. ADLER, A. Social interest: a challenge to mankind. New York: G. P. Putnam's Sons. 1939. 2. ELLIS, A. An introduction to the principles of scientific psychoanalysis. Genet. Psychol. Monogr., 1950, 41, 147-212. 3. FENICHEL, O. The psychoanalytic theory of neurosis. New York: W. W. Norton & Co., Inc., 1945.

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4. FREUD, S. Collected papers. London : Hogarth Press, Ltd., 1924-25. Vols. I-IV. 5. . The basic writings of Sigmund Freud. New York: Modern Library, Inc., 1938. 6. FROMM, E. Escape from freedom. New York: Rinehart & Co., Inc., 1941. 7. HILGARD, E. R., and MARQUIS, D. G. Conditioning and learning. New York: Appleton-Century-Crofts, Inc., 1940. 8. HORNEY, K. The neurotic personality of our time. New York: W. W. Norton & Co., Inc., 1936. 9. . New ways in psychoanalysis. New York: W. W. Norton & Co., Inc., 1940. 10. HULL, C. L. Principles of behavior. New York: Appleton-Century-Crofts, Inc., 1943. 11. JACOBI, J. The psychology of Jung. New Haven, Conn.: Yale University Press, 1943. 12. JUNG, C. G. Contributions to analytical psychology. New York: Harcourt, Brace & Co., Inc., 1928. 13. KOHLER, W. Gestalt psychology. New York: Liveright Publishing Corp., 1947. 14. MULLAHY, P. Oedipus: myth and complex. New York: Hermitage Press, 1948. 15.

16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

NATIONAL SOCIETY FOR THE STUDY OF EDUCATION.

The psychology of learn-

ing. Forty-first Yearbook. Bloomington, 111.: Public School Publishing Co., 1942. NICOLE, J. Psychopathology: a survey of modern approaches, Baltimore: The Williams &~Wilkins Co., 1947. RANK, O. Will therapy and truth and reality. New York: Alfred A. Knopf, Inc., 1945. REICH, W. Character-Analysis. New York: Orgone Institute Press, 1949. REIK, T. Listening with the third ear. New York: Farrar, Strauss & Young, Inc.. 1948. ROGERS, C. R. Counseling and psychotherapy. Boston: Houghton Mifflin Co., 1942. SEARS, R. R. Survey of objective studies of psychoanalytic concepts. New York: Social Science Research Council, 1943. STEKEL, W. Techniques of analytical psychotherapy. New York: W. W. Norton & Co., Inc., 1940. SULLIVAN, H. S. Conceptions of modern psychiatry. Washington, D. C.: The William Alanson White Psychiatric Foundation, 1947. SYMONDS, P. M. The dynamics of human adjustment. New York: AppletonCentury-Crofts, Inc., 1946. WOODWORTH, R. S. Contemporary schools of psychology (rev. ed.). New York: The Ronald Press Co., 1948.

Chapter 4 HUMAN INFANCY AND THE EMBRYOLOGY OF BEHAVIOR By ARNOLD GESELL, Ph.D.,

M.D.

HUMAN INFANCY is a period of genesis and growth. But the genesis of this genesis must be sought in the vastly longer period of organic evolution. The human infant in a true sense is the focal end product of countless ages of racial prehistory. Infancy was evolved to subserve the needs of individual growth and to supply the conditions for continuing evolution. Every infant, accordingly, comes into the world with potentialities of growth which normally perpetuate the essential traits of the species. He is also endowed with a margin of modifiability which makes for innovation and mutation. No one needs to teach him how to grow. The capacity to grow is an intrinsic part of the instinct to survive. The tendency of all growth, both in normal and in handicapped children, is toward an optimal realization, and Nature is prolonging the period of infancy to permit a wider and higher range of realization. George Bernard Shaw, however, was not altogether satisfied with these arrangements. He suggested that by the year 31,920 A.D. Nature may have improved her techniques. In his Back to Methuselah: A Metabiological Pentateuch, he pictures a dramatic scene in which a huge egg upon an altar begins to rock. Presently there emerges "The Newly Born, a pretty girl who would have been guessed as seventeen in our day." She "sits up in the broken shell, exquisitely fresh and rosy, but with filaments of spare albumen clinging to her here and there." She had been growing for two years in the egg and in that time passed through a development which nowadays (192051) costs human beings some twenty years of "awkward stumbling immaturity" after they have been born. Despite these whimsical strictures, the human life cycle as of today remains biologically a most complicated and even an awe-inspiring spectacle. Into the early sectors of this cycle there are compressed millions upon millions of years of prehuman evolution. The germinal cells which initiate a cycle of growth are, in a sense, very new, but 51

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each has a phyletic history which recedes into remote geologic epochs. By the same token, the embryo, fetus, and newborn infant are biologically very ancient. The toddler walks and leans with a posture which suggests primitive mankind. Yet he is at the same time so untutored in our modern culture that we rightfully regard him as something unique and recent under the sun. Phylogenesis and ontogenesis are so profoundly interrelated that the cycle of development is charged with paradoxes and relativities. The younger the organism, the faster it grows old. Newtonian time, which we use to measure chronologic age, flows at a uniform rate in either direction. But development flows with a negative acceleration in unidirectional time, and, of course, it is irreversible. If an infant is born prematurely, he has three ages: statutory chronologic age, registered by the bureau of vital statistics; corrected chronologic age, which discounts for his prematurity and is reckoned from conception ; developmental age, which expresses his biologic completeness on the basis of a developmental diagnosis. For accuracy, he must be called a fetal infant during the period of his prematurity, that is, from birth until he reaches a postconception age of forty weeks (see Figure 1). Our clinical studies have shown that uncomplicated prematurity does not markedly alter the course of postnatal development. Irrespective of the time of birth, the viable infant tends to cleave to a basic ontogenetic sequence. Uterine Development Ontogenesis in utero and ex utero reveals itself in three major manifestations: somatic, physiologic, and behavioral. At a postconception age of eighteen days, the human embryo, as shown by the Heuser specimen, is a patch of protoplasm, measuring 1.53 mm. in length and 0.75 mm. in its greatest width (see Figure 2). The ground plan of a potential organism is already foreshadowed in the construction of this tiny disk of tissue. The longitudinal axis has been laid down: the embryo has a left and a right side, a dorsal and ventral aspect. The primitive node, a conspicuous white spot behind the center of the disk, marks the junction of the head and neck. Indeed, almost three fourths of the disk is already set aside for the formation of the head (12). Human development places a premium on the head—and on the heart. Morphogenesis proceeds at a prodigious pace. Presently the embryonic heart takes shape. By the fourth week it begins to beat, initiating the most durable of all behaviors. The eyes are almost

FK, 2 Pliotouraph of a human embryo. ai>e eighteen da\ i A dorsal view through the transparent .mimon. The pear-shaped disk is 0.75 mm In 1 53 mm, in dimension The primitive node marks the junction of the lit ad and neck structures After Heuser i 1J>

Human emhr\o approaching fetal age of 'M'st MTt nimementv make their appearance In 1 n< reflected, expo.sing tin pellucid amniotic sit-

in week* the ^tace ulien tht thi chorionii villi

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equally precocious. By the end of the fourth week the optic vesicles are fully formed. In the fifth week limb buds, precursors of arms and hands, emerge. In the sixth week the retina of the eye, and in the seventh week the semicircular canals of the ear and the oculomotor muscles, begin to differentiate. Near the eighth week (see Figure 3) the region about mouth and neck becomes reflexogenous. Hooker, in his notable studies, has shown that at this stage stroking this area with a hair stylus elicits a lateral flexion of trunk and neck with slight rotation of the pelvic region. At the same time shoulder muscles contract causing the arms to move stiffly backward. In a half-second the fetus returns to the original attitude (13). Thus it has been demonstrated that approximately eight lunar months prior to birth the embryo is capable of an overt configured pattern of behavior. The patterning of behavior continues in a regular ontogenic sequence, generally from head to foot and from proximal to distal segments. By the fetal age of twelve weeks a wide variety of muscle reactions make their appearance, most of them involving the fetus as a whole (Figure AA). There are spontaneous rhythmic contractions of the trunk alternating from side to side. By this time the semicircular canals have attained adult size, and it is not impossible that the fetus already responds with some aquatic skill to stimuli from the vestibular apparatus of the ears. Fingers have formed; stimulation of the palm elicits extension of the wrist, and, at a somewhat later stage, the fingers flex and grip. By twelve weeks the arms and hands have rotated from the early paddle position, so that the palms now face each other. In response to a facial stimulus, both hands may move toward the median plane. This bilateral response foreshadows in an interesting manner a comparable prehensory reaction of the full-term infant at the postnatal age of twenty weeks, when the total reaction comes under visual voluntary control (see Figure AD). We may call this a symmetro-tonic reflex, bearing in mind that asymmetric patterns of behavior will appear in later development. It is not too early to consider vision. Even though the eyelids at the fetal age of twelve weeks are still fused, the prerequisites for eyehand coordination are already in the making. The oculomotor muscles are undergoing innervation, and the eyeballs have been observed to move beneath their sealed lids. These eye movements increase in strength and in pattern as the fetus matures. It is impressive to realize that the eyes are active in a motor sense throughout a period of seven lunar months prior to full-term birth. The fourth month of gestation is in many respects the most varie-

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gated in the prenatal ontogenesis of behavior, because the fetus exhibits an extremely diverse repertoire of elementary movement patterns. In fact the entire skin is becoming reflexogenous (13). Restricted specific reactions supplement the general postural responses, but the action system maintains a basic unity. The specific patterns arise through individuation out of a total unitary pattern. The patterns may at times function in apparent isolation, but there is no adequate evidence that the embryology of behavior proceeds by a linking together of multiple independent specific reflexes. By the end of the fifth gestation month the fetus is approximately a foot in length and a pound in weight, and is well advanced both in somatic and functional organization. The countenance has taken on a somewhat personable appearance and is already stamped with individuality. Although the nervous system is by no means finished, the infant is in possession of a full quota of neurones, perhaps twelve billion in number. The mechanisms of vision are now still further advanced. Although the fetus has no light by which to see, the anatomical arrangements for seeing have been deeply laid. The optic nerve is equipped with its million fibers, 90 per cent of them reaching the cortex by way of the lateral geniculate bodies, which serve as a mediating mechanism for the macula, the area of most acute vision. The macula begins to differentiate as early as the third gestation month. In another fortnight the layers of the retina will have been differentiated, the fovea centralis in each retina established by a thinning of the ganglion cells to form a shallow surface depression. At the time of its formation the fovea is as far distant from the optic nerve head as it is in the adult eye—an arresting fact when one considers the tremendous anatomical changes which are yet to follow during the latter half of the gestation period and throughout the postnatal period of growth, for the eye itself will more than double in weight prior to birth. Moreover, the eye and the brain will increase three and a half times in weight from birth to maturity, and the body as a whole will increase twenty-one times. Nevertheless, the distance between the fovea and the nerve head as established at the fetal age of twenty-four weeks remains unchanged (15). This fact certifies to the profound importance of vision in the organization of human behavior. The macula in a sense becomes a fixed pivot in the process of morphogenesis. This is also an impressive instance of developmental fore-reference, because macular vision with its rich cortical and subcortical elaborations requires many years of continuing development throughout infancy and childhood. Theoretically, this anachronistic mixture of adult and embryonic char-

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acters indicates the limitations of a simple chronological concept of recapitulation (2). Nature has a double problem: to crowd as much development as possible into the uterine period, and, at the same time, to make ample anticipatory provisions for a distant future. Moreover, there is the additional and fateful contingency of premature birth. Always there is the difficulty of reconciling the physiology of the maternal organism with that of the "parasitic" fetus. Often the difficulty is so great that gestation miscarries, and the fetus is stillborn or blemished. These complications are mentioned in passing, because they affect the patterning of human behavior. Prenatal development is dependent upon degrees of compatibility between the life cycles of mother and child. The Fetal Infant At no point in the cycle of human life do individuals exhibit such a wide array of differences as at the moment when they are born. This is due to the relativities of natal age, to congenital differences in physiological adequacy, and to differences in behavioral capacity. Infancy begins at birth. A full-term infant is one whose gestation period was approximately forty weeks. A preterm or premature infant is one whose gestation period was less than thirty-seven weeks (birth weight 2,500 grams or less). A preterm infant is called a fetal infant from birth to the fortieth postconception week, as reckoned by birthweight age. As an insurance factor against the hazards of premature birth, the machinery for breathing, involving cooperation of nerve elements, undergoes a hastened development in the fifth, sixth, and seventh gestation months. A single shallow exhalation followed by inhalation has been observed even earlier. In a surgical fetus twenty-two weeks old, the spasm movements occurred in short runs of two or three exhalations and inhalations. By twenty-five weeks these rhythms are no longer spasmodic, but sufficiently continuous to support life for several hours (2). By twenty-eight weeks the respiratory mechanism is often sufficiently advanced, under conditions of modern pediatrics, to insure survival. At this early stage (twenty-eight to thirty-two weeks) the fetal infant is small enough to be held in the palm of the adult hand. The muscular tone is minimal, flaccid, and uneven. Occasionally there is movement, but the distinction between activity and rest is not clearcut. The fetal infant neither really sleeps nor wakes, but only drowses, with brief periods of bodily activity. The torpor is fluctuant

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and shallow but is the most conspicuous and consistent behavior at this stage. In the supine position, the infant tends to lie with head turned to one side with the arm on that side extended, the opposite arm being flexed (Figure 4B). This represents the classic tonic neck reflex (t-n-r) pattern which is of far-reaching significance in the patterning of behavior. The symmetro-tonic reflex (s-t-r) is characteristic of an earlier fetal stage. At times the fetal infant activates the extended arm and holds it in a transient catatonic pose. Although general bodily activity is sporadic and meager, he is seldom completely quiescent for any length of time. The facial musculature is busy: the tongue protrudes; the lips purse, munch, and mince; the eyelids flutter in unison or in succession; the eyebrows lift together or separately; the forehead corrugates (sometimes only half of the brow is involved, for bilateral integration is not yet firmly achieved) ; the oculomotor muscles roll the eyeballs or weave them back and forth and up and down; the eyeballs usually move conjointly, but positive visual responses are scanty or quite absent. Bodily movements are generally sporadic ripples of activity. In another month (thirty-two to thirty-six weeks) the fetal infant, although still a drowsy individual, shows a capacity for brief periods of wakeful alertness. Again and again during the day and during the night, the torpor is disrupted by small acts of awareness. The infant does not give true regard to an object slowly moved across the field of potential vision, in fact he does not even fixate upon it, but the eyes do move irregularly in brief after-pursuit. The late-stage fetal infant (thirty-six to forty weeks) presents a more finished appearance. Increased deposits of fatty tissue have now rounded the body contours. He is physiologically more robust, and the behavior patterns are more distinctly configured. Having had a month or more of experience in an atmospheric world, he functions more smoothly, if not more maturely. He has learned the knack of sleeping, and he falls off to sleep more decisively, sleeps more deeply, clings to sleep more tenaciously. During the brief waking interludes he takes some visual notice. The ability to wake up, like all complex behaviors, is based upon morphogenetic changes in the central nervous system. The waking propensity requires special neurological arrangements which, at the present stage, are probably organized chiefly in the thalamic region of the brain—the equivalent, according to Kleitman, of a primitive waking center. When the late-stage fetal infant reaches a postconception age of forty weeks, he is chronologically equivalent to a newborn infant of full term. Premature birth has provided lengthened experience in a world of

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light and air. The behavior characteristics observed at this stage afford some indication of the ontogenesis which takes place unobservably in the latter months of full-term uterine development. Having had some weeks in which to refine his adaptations to an extrauterine environment, the fetal infant may function more smoothly than the full-term neonate of equivalent postconception age. For a brief period the more experienced infant appears better organized and physiologically more expert, but these differences are transient and do not confer any permanent fundamental acceleration. The fact that prematurity, uncomplicated by damage or disease, has no marked effect upon the sequences of behavior development indicates that the entire course of ontogenesis is well ballasted by intrinsic maturational determiners. Maturation may be defined as the net sum of the gene effects operating in a self-limited life cycle. The basic genes of an individual may be regarded as agents which control biochemical reactions in a sufficiently specific manner to determine the basic sequences of ontogenesis. These sequences manifest themselves in characteristic body structures and equally characteristic forms of behavior. We have dwelt at some length on the prenatal phases of ontogenesis, because they illustrate most strikingly the power of the maturational mechanisms. There is no evidence that these same mechanisms cease to operate during the postnatal periods of infancy and childhood. To be sure, the newborn infant is plunged into a novel environment, highly charged with complex cultural forces which impinge upon him relentlessly during all his waking hours. Nevertheless, both by night and by day, the maturational mechanisms, based upon the gene complex, proceed with even greater relentlessness. The impacts of culture are incessant but by no means all-powerful. The infant is durable as well as docile. The degrees and the directions of his acculturation are in no small measure determined by inherent behavior traits and trends. Charting the Patterns of Infant Behavior Growth is a patterning process, whether we think in terms of the physical organism or the functional forms of the organism. Adopting a thoroughgoing monistic approach, we are under no necessity of defining a causal interaction between body and mind. We simply assume that as the soma takes shape the psyche likewise takes shape. We are dealing with a single developmental morphology. The "mind" of the infant is made manifest in patterns of behavior—

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in spontaneous and induced reactions which can be studied by objective methods, as described elsewhere in detail (1, 3, 4, 10, 11). Working as a cooperative research group, the staff of the Yale Clinic of Child Development have charted behavior traits and trends characteristic of thirty-four levels of maturity from birth to ten years of age. Motion-picture records were systematically made to document the behavior patterns of normal infants at lunar-month intervals during the first year of life. Taking a hint from astronomy, a photographic observation dome was contrived and equipped with motionpicture cameras mounted on two quadrants. The cameras, however, did not point to the heavens; they were directed inward to a central universal focal area occupied by an infant who put forth his appropriate patterns of behavior for the cinema record. The dome was encased in a one-way-vision screen which effectually concealed the observers. All arrangements, personal and technological, were designed in behalf of the infant to promote an optimum of behavior on his part. An adjustable examining crib was used to set up standardized test situations and to elicit characteristic patterns of posture, locomotion, eye-hand coordination, and various forms of adaptive behavior. The accompanying illustration (see Figure 5) pictures a twenty-eightweek-old infant seated in a supportive chair, confronting a table top on which a test object has been placed. The photographic film records the resultant behavior—the reach, the grasp, the exploitation. The cinema captures the behavior, remembers it infallibly, and makes it available for morphological study. Some three thousand action photographs have been codified in An Atlas of Infant Behavior (11). By the method of cinemanalysis (see Figures 6 and 7), it is possible to reconstitute and dissect the pattern characteristics of behavior in terms of time and space. This method of intimate inspection provides an objective approach to the postnatal embryology of behavior. It does not, of course, resolve all the mysteries of what we call the infant "mind." But it makes the manifestations of the mind almost as tangible as tissue. The cinema registers moments and episodes of behavior, but it also documents the ontogenetic progressions from age to age. To see these transformations in the perspective of their lawful unfoldment is to realize that the infant mind is a living organic reality which has structure and architecture shaped by deep-seated mechanisms of growth.1 1 To convey the scientific and clinical significance of these mechanisms, a conceptual teachingfilmwas recently produced under the auspices of the Office of Naval

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For a summary view of the total postnatal growth of infant behavior, it will be convenient to discuss the developmental trends under the following headings: (a) eyes-hands-feet; (b) language and thought; and (c) the interpersonal self. Since development in general proceeds from head to foot, the eyes enjoy a top priority. Eyes-Hands-Feet In the evolution of prehuman behavior, it appears that the olfactory area and the sense of smell began to recede when the forelimbs were freed for purposes of prehension and feeding. Eocene Tarsius must have lived on a hand-to-mouth basis, with increasingly alert eyes. This involved an enormous development of the portion of the cerebral cortex responsible for vision. All that has happened since in the anthropoid humanoid stocks, which emerged after the tarsiers, has tended to enhance and to enrich the visual functions. The brain nucleus for accommodation was remodeled in the primates, and was divided so that each eye could be focused independently upon any object. The sense of smell, once in the lead, has declined, and the eyes have attained a priority in the constellation of the sense organs. The eye, however, has not become overspecialized, but continues to show a remarkable adaptability in meeting environmental demands without exaggerated development of any one of its several components at the expense of others. Overspecialization would have led to isolation from other areas of sense and movement. This generalized biological adaptability suggests that even under cultural stress the human eye will prove equal to new demands and maintain a supremacy without weakening the unity of the action system. It is evident that its evolutionary potentialities have by no means been exhausted (17). The human hand, likewise, remains in a primitive and very generalized condition and may well continue capable of many new refinements in the evolution of the action system. Something also should be said about the foot of man. Although it is not directly concerned in the mechanisms of vision, the foot is one of the most specialized and distinctive features of human anatomy. In a very real sense, it is the foundation of distinctive visual skills, because the feet have become the "arch platforms" which permit man to maintain an erect posture and to bestride the earth as a partial master of destiny, eyes Research and the Medical Film Institute of the Association of American Medical Colleges. This is a full-length (1,000 feet) 16-millimeter color film, entitled The embryology of human behavior, with spoken commentary by the author.

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forward. This posture and distinctive mode of locomotion have also favored reorientations and new conquests in the sphere of vision. The forces of evolution had to provide continuously for a harmonious interadjustment between eyes, hands, and feet. In this sense, the feet do figure in the economy of vision and cannot be disregarded in any account of the embryology of child behavior. In the early patterning of behavior, the eyes assume a lead, and in a sense the infant takes hold of the world with his eyes long before he does so with his hands. During the first eight weeks of life, the hands are predominantly closed, but the eyes open to fixate, to stare, and to seek. Conjugate and coordinate compensatory eye movements are present soon after birth. Incipient fixation of an approaching object in the field of vision is observable in the first day of life, longer fixation in the first week, and well-sustained fixation of near and far objects at the end of the first month. In its earliest stage, fixation is typically monocular (Figure 8). The active eye immobilizes except for minute lateral and vertical movements which cause the fovea to traverse a stimulus area. The nonfixating eye rests or wanders willynilly. In the next stage the monocular fixation alternates rapidly from one eye to the other, the shifts being accompanied by a rhythmic left-to-right-to-left rotation of the head (14). This interesting stage of monocular alternation of dominance leads directly into binocular convergence, which makes its appearance in the second month. The teaming of the two eyes is an extremely complicated phenomenon. It involves complex aspects of fusion, stereopsis, and cortical interpretation, which undergo progressive organization throughout the years of infancy and childhood. During the third month transfixed regard gives way to roving inspection, and the eyes begin to look selectively at objects which move in the field of near vision. During the early months the tonic neck reflex attitude plays a significant role in the developmental organization of visual behavior. Repeatedly and often prolongedly, the infant gazes in the direction of his extended arm, as though he were regarding his own hand, whether moving or still. This attitude promotes and channelizes his visual fixation; it leads to fleeting eye-hand coordinations, later to prehensory approach, and eventually to various forms of unidexterity —eyedness, handedness, and also footedness. In another month, at sixteen weeks, the hands decisively enter the behavior picture, supplementing and even activating the posturing of the eyes. When the infant is supine, the head now favors a midposition rather than aversion, and concurrently the hands come to-

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ward the mid-plane, to engage, to clutch, and to finger. Fingers finger fingers, thus bringing active and passive touch into close association. The infant cannot reach on sight, but in response to a tactile cue an object is grasped after it is placed in the palm. Nevertheless, eyes and hands are coming into coordination. This is beautifully shown when the infant is propped in a supportive chair, confronting a gray table top, on which a red one-inch cube is placed. The infant is pleased with this sedentary position, and feels an urge to erect eyes, head, and shoulders. He is avid for visual experience and holds his head steady, looks down intently at the table top, at his own hand, at the cube, again at his own hand, and perhaps again at the table top. One or both hands begin to scratch the surface of the table. Presently he shifts his regard to the surroundings or the nearby examiner. We have used the one-inch cubes systematically in our clinical examination of infants. The cubes have a universal appeal, and when administered under standardized conditions, they elicit behavior patterns which have considerable symptom significance. Repeating the cube test on numerous subjects, we find that there is a consistent difference in the visual-motor responses at advancing age levels. The behavior patterns fall into growth gradients, which reflect lawful sequences of ontogenesis. In another lunar month, when the infant is twenty weeks old, we place upon the table top a white pellet 7 mm. in diameter. The infant gives it definite regard, the hand usually remaining passive, for this is an exacting visual test. He unquestionably picks up the pellet with his eyes, even though he will not pick it up readily with his fingers until twice his current age. At forty-four weeks he plucks the pellet promptly, with precise pincer prehension and neat thumb opposition. These are genuine embryological phenomena. Prehension is not a mere skill, acquired through practice and learning, for at each progressive age the infant functions with a new mode of response in the following genetic order: (1) fitful, sketchy regard of the 7 mm. pellet (twelve weeks) ; (2) definite regard of pellet without manual approach (twenty weeks) ; (3) prehends one-inch cube on sight (twenty-four weeks); (4) rakes in vicinity of pellet with conjoint flexion of fingers (twenty-eight weeks); (5) prehends pellet on sight, by crude lateral forceps approach (thirty-six weeks) ;

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(6) prehends pellet pincerwise by adept oblique approach (fortyfour weeks). Under the stress of intrinsic growth, the human infant is constantly abandoning one form of behavior for another form which is maturationally more appropriate. Even after he has "learned" to take up (and eat) a sugar pellet, with dispatch, by a gross palmar scoop, he adopts a more delicate and difficult digital method of prehension, using it persistently despite initial awkwardness and failure. The environment lacks the architectonics to generate such basic progressions and reconfigurations in the patterning of infant behavior. There appears to be a ground plan of development governed by an inherent dynamic morphology imposed by the phyletic history and by the developmental anatomy of the human action system. The combined developmental and morphological trends are so profoundly related to gravity, light, and space that they can conceivably be reduced to mathematical formulation, as already adumbrated in D'Arcy Thompson's classic work On Growth and Form. Ontogenesis is an organic time-space cycle of forms, whether considered physically or functionally. Thompson has given the most succinct definition of a form; it is "a diagram of forces." An ontogenetic sequence is evident in the formation and transformation of cube behavior observable during the first five years of life. At twenty-four weeks of age, the infant at the test table leans forward and seizes a cube on sight. At twenty-eight weeks, having seized the cube, he transfers and retransfers it from one hand to the other—a remarkably universal behavior pattern, entirely untaught, and without even the reinforcement of a nursery game. At forty weeks, a cube is held in each hand and the two are brought together exploitively in the mid-plane. At one year, with several cubes before him, the infant picks them up one by one and releases them one by one, exercising a new power of voluntary inhibition. This seriational behavior is an ontogenetic prerequisite for a higher action pattern which is called counting. The infant tends to release the cubes in random array; but at eighteen months, spontaneously and responsively he builds a tower of blocks—a vertical seriation, and at two years builds a wall—a horizontal seriation. At three years he surmounts two buttress cubes with a third, combining horizontal and vertical components in the construction of a bridge (Figure 9). At four years the keystone cube is tilted by an oblique maneuver to make a gate. At five he rearranges six cubes into a three-step stairway, combining vertical, horizontal, and oblique directionalities. "Nature geometrizes," said Plato. Her geometry is implicit in the developmental

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anatomy of the nervous system. It is tempting to suggest that the embryological trends which the child shows in the various stages of his block play and block building in some way correspond with the stages through which the race passed in its primitive contests with gravity and space. Early man began to contrive and to use tools as soon as he adopted the erect posture, which served to free his forelimbs for the higher uses of manipulation. Eyes came into their own. Vision became more completely the master guiding sense, directing his fumbling hands and feet into increasingly elaborate pathways. With respect to the interaction between eyes, hands, and feet, it is idle to differentiate between cause and effect. Recent fossil finds in South Africa suggest that a prehuman Plesianthropus walked erect with eyes front, some seven million years ago. It takes the average human infant about sixty weeks to attain the ability to walk alone, even with a toddling gait. The developmental mechanics of this locomotor ability are extremely intricate. The diagonal reflexes and the tonic neck reflex postures of the fetus are part of the ontogenetic sequence. We have identified twenty distinguishable stages of postnatal prone behavior, beginning with a passive kneeling stance and culminating in plantigrade creeping, a quadrupedal form of locomotion on palms and soles (Figures 10 and 11). The final transition from quadrupedal to bipedal walking may be rather sudden, but the earlier transitions bespeak a long and tedious phyletic history. For some six months, the prone infant fails to progress even though at advancing ages he thrusts his knees, extends his legs, and assumes froglike attitudes. In due course he pivots, but with no locomotor advance. Later he crawls upon a groveling abdomen. Still later he assumes a creeping stance, resting on hands and knees. At one stage he combines creep and crawl; at another he regresses; at still another he rocks, going neither backward nor forward. At about forty weeks he pulls himself to a standing position, by grasping a support. By eighteen months he usually becomes an independent runabout, but his postures and locomotions still show primitive traits (7). It would be difficult to establish a chronometric recapitulatory parallelism between racial and individual stages. Eyes and hands have been given a double priority in the ontogenetic sequence. Yet there are certain suggestive correspondences between the organization of eye-hand coordination and that of general body control. At twenty-eight weeks when the hand still functions in a palmar, not to say paw-like, manner, the infant can sit erect only momentarily. At

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forty weeks when he rises to his feet by a brachiate pull, the digits of the hand are becoming functionally specialized. The American infant at this age is under an irrepressible compulsion to poke, to pry, and to probe with his index finger, which he uses as though it were a tool, as indeed it is. He uses his finger as an awl to thrust, as a lever to pry, and, with the now opposable thumb, as a pincer. Pincerwise he plucks the end of a string and instrumentally uses the string to pull a distant object into the scope of his ceaseless manipulation. He is already an elementary tool user. By the age of two he will have partly mastered one feeding utensil; he will be able to feed himself with a spoon, keeping the bowl right side up as he puts the spoon into his mouth. In manipulative and exploitive behavior, the infant displays considerable resourcefulness. Despite his tender age, he demonstrates an extraordinary capacity for original activity and discovery. A baby is thus seen to be not only the embodiment of a future adult but also a generic embodiment of the venerable past of the human race. His growing nervous system is the carrier of an immense series of evolutionary adaptations, by means of which the race has consolidated its most essential achievements. These achievements are now the common property of mankind, but once they were creations. The evolution of human infancy has in itself been a creative process. The human infant as the current custodian of that process revives in telescoped compression some of this immemorial creativity. Language and Thought Thus far we have considered chiefly the sensorimotor equipment by means of which the infant manipulates spatial relationships. The genesis of his thinking must be sought in this same equipment and the uses to which it is put. His action system develops as a unit, and both his practical and conceptual intelligence are rooted in prehensions, manipulations, and locomotions. Even his symbolic apprehensions (a semantic pun!) may be traced to sensorimotor contacts with the concrete. Language, therefore, has a motor basis. Primitive language is mediated by postures, by facial expression, by manual gestures, and by vocalizations. Under the impress of culture, the vocalizations become articulate and the child learns to speak. Ultimately his words become vehicles of thoughts and even of trains of thought. His linguistic and intellectual acculturation, however, is limited at every turn by maturational factors.

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The manner and the order in which a child acquires speech reflect stages and patterns of neuromuscular maturity. At four weeks of age his utterance, apart from crying, is restricted to small throaty sounds. At eight weeks he vocalizes single vowel sounds (ah, eh, uh). At twelve weeks he chuckles; at sixteen weeks, laughs; at twenty weeks, squeals. By twenty-eight weeks he usually is capable of making polysyllabic vowel sounds and a consonantal m-m-m. By the first year he imitates sounds, and has a word or two in his vocabulary. At fifteen months he frequently uses a jargon which seems formless, but is configured by inflections and rhythms. The jargon is a developmental matrix for words which ordinarily begin to multiply in the period from eighteen months to two years. At two years jargon is usually being displaced by three-word sentences, including the use of pronouns. At three years the child begins to use prepositions and plurals with some facility. The foregoing sequence has ontogenetic import. The ages assigned are, of course, approximate and subject to individual variation. The order of emergence of the language abilities, however, is of developmental significance with respect both to expression and comprehension. A recent study of the speech production of preschool children at the Yale Clinic of Child Development has shown indubitable growth trends in the period from eighteen to fifty-four months of age. The correct production of each of the consonant and vowel sounds does not proceed from age to age in gradual advance toward specificity, but shifts with repeated regressions and progressions. The mastery of consonants in terms of phonetic placement progresses from labial to glottal to post-dental to labial-dental, that is, from front to back to middle. Vowel sounds progress from back to front to middle. Maturational rather than environmental factors account for such trends (16). Thought might be defined as a manipulation of meanings. Words whether spoken or unspoken are devices for facilitating such manipulation. But when an infant or child manipulates objects in a meaningful manner, even without overt or inner speech, he may nevertheless be thinking. Primitive thought in the race was on a similar nonverbal level. The thoughts of the growing child are variously passing through developmental stages of egocentric concreteness, specific naming, conceptual generalization, judgment, animism, magic, syncretism, reasoning. Child logic, as Piaget has brilliantly shown, is a subject of infinite complexity which involves problems of genetic psychology and even of epistemology. Here we simply wish to suggest that the mental growth of the child is basically obedient to dynamisms which

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are the end product of evolution. He does not in a semantic sense relive the thoughts and experiences of his remote ancestors, but he probably ascends to sophistication by comparable dynamic steps and mechanisms. Indeed, if the knowledge were available, we might well find that the ontogenetic development of general intelligence most completely duplicates the phyletic modalities of evolution. Even our highly technologic culture modernizes the contemporary child only by slow degrees. Although he begins to ask "how" and "why" questions at four, five, and six years of age, he still has much difficulty in distinguishing between fantasy and reality. At these ages he has a strong interest in magic. He draws simple rational deductions, within the narrow limits of his experience, but he may be quite unable to explain how a bicycle operates. By the age of ten years, however, he thinks more readily in terms of general mechanical causes. He is less naive, his errors of interpretation are fewer. His modes of thinking and his attitudes toward cause and effect have become truly scientific in quality. Even scientific attitudes are subject to growth factors. We detect a developmental gradient in the typical reactions to the Santa Claus myth. Up to the age of two and a half years the physical Santa is commonly feared. Most three-year-olds are aware of Santa long before they are aware of God. The four-year-old is a true believer and accepts every detail of the myth. The five-year-old embraces the realism of Santa's clothes, his laugh, his reindeer. The six-year-old believes with emotional intensity. If he has a lively mind, he imagines not only old Santa himself, but Santa's wife, home, workshop, and the ledger in which are enrolled the names and deeds of good children. The reflective seven-year-old has moments of skepticism or, rather, moments of constructive criticism. He may repudiate the details but adheres to the core of his faith. At age eight the notion of Santa Claus is more etherealized, but by no means surrendered. By age ten the Santa myth has been generally abandoned and, in well-constituted children, probably without psychic trauma. The ten-year-old has become less naive and more rationalistic. He ascribes natural origins and natural processes to nature and to man, and over the cosmos he may be erecting a supreme deity. His interest in magic has greatly diminished. He has attained a preliminary stage of maturity where, at a juvenile level, he can combine science and religion in a simple "philosophic" outlook (9, 10). To what extent he will continue in later years to think abstract thoughts and to elaborate ideas will depend primarily upon the growth potentials of his nervous system. There is an embryology of be-

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havior which may continue even beyond the traditional chronologic limit of maturity. The nervous system not only registers and organizes the past experience of the organism, but brings into being new thoughts and new insights. Such creative acts are acts of growth in the sense that they depend upon the capacity of the neurones to continue an embryonic type of development. In this manner, some of the plasticity of early infancy is prolonged into the later sector of the life cycle. The Interpersonal Self It remains to inquire, at least briefly, whether the developmental mechanisms already described operate also in the organization of the child's personality—his emotional attitudes, his morals, his social behavior. Having emphasized the unity of the action system, we begin with the premise that his "self," his individuality, is part and parcel of that action system. It is an organic product of growth, in a world of things, and more especially in a world of persons. From the moment of birth, the human infant feels the impacts of personal care and ministrations. He is an individual, but he is not an encapsulated ego. He soon begins to sense the unremitting care which he receives. He senses it through passive touch, through hearing, but above all through vision. If he did not establish countless contacts with other human beings, he could scarcely acquire a personality recognizable either to himself or to others. The makeup of his personality depends upon the interpersonal relationships which he experiences from day to day and from age to age. His self is of necessity interpersonal in many aspects of its developmental history. No two infants were ever born alike. No two infants were ever reared alike. The individual differences which distinguish infants, therefore, have a double derivation—the genes of ancestral inheritance and the endless variations in the personalities which constitute families, schools, and communities. However, no infant is so individual that he ceases to belong to his species and to a racial stock. Although he is sensitive to cultural impress, he has a biological equipment which sets limits to that impress and which also determines the directions, the modalities, and the intensities with which he reacts to his personal environment. In sketchy outline it is possible to indicate the maturational stages whereby the growing self takes shape through interaction with other selves. The age levels which will be designated are not to be taken too rigidly. They are, however, based on observations of numerous

FIG. 5. The infant in the clinical crib is reacting to a standardized test situation.

FIG. 6. Photographic dome for recording infant behavior patterns. The dome encased in a one-way-vision screen to conceal observers.

FIG. 7. The method of cinernanalysis. Cinemanalysis is a method of observation which permits one to examine the successive phases of motion with deliberation. The simplest device for accomplishing this analysis is an ordinary projector, mounted on a portable vertical stand which rests on a desk or table. The projector is operated by a small handcrank and throws an image four- by five-inch in size upon a white enamel plate. The operator controls the successive images by means of the crank. He employs the analytic viewer in much the same way that he would use a microscope for histologic study. In one case he examines a specimen of tissue; in the other, a specimen of behavior. The cinema film consists of a series of individual still frames as shown at the right. Each frame pictures a phase of motion. The film can be observed in motion. Any individual frame can be stilled for close study.

FIG. 8. Left tonic neck reflex in infant age thirteen days, showing monocular fixation by right eye.

FIG. 9. Combining horizontal and vertical components to construct a bridge, this three-year-old boy is arranging the buttress blocks. A four-year-old boy combines horizontal and oblique components to construct a "gateway."

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children and suggest typical trends. As early as the age of four weeks the infant reacts to social overtures by a reduction of general activity; at eight weeks his face animates to the point of smiling; at twelve weeks he both vocalizes and smiles in social response. At sixteen weeks he is capable of spontaneously initiating a social smile, and he displays recognition signs on the sight of his mother. At twenty-four weeks he begins to discriminate strangers, and at thirty-two weeks he may withdraw from them. He soon exhibits a remarkable perceptiveness in reading facial expressions. Toward the end of the first year, he participates increasingly in two-way nursery games. These games, from Peek-a-Boo to rolling a ball back and forth, set up a to-and-fro reciprocity. The situations are simple, but they are in accord with a universal dynamism of development which continues throughout the period of childhood. Sometimes the dynamism accentuates the child's ego; sometimes it accentuates the opposite partner. The accents vary with age as well as temperament. At two years of age the child calls himself by his own name and shows a new sense of possessiveness. At two and a half years he uses the pronoun " I " with imperiousness. He does not have himself well in hand and has difficulty in distinguishing between mine and thine. He is discovering a new realm of opposites. Life is no longer a one-way street as it was at eighteen months, but is charged with double alternatives, and he finds it hard to make simple choices and decisions. This is essentially due to his immaturity, for at the age of three years he will take pleasure in making voluntary choices which lie within the range of his ability. Meanwhile, because of his bipolar confusions, the two-and-a-half-year-old tends to be variously impetuous, hesitant, "contrary," dawdling, defiant, or ritualistic. He needs skilful guidance, which is more readily given if one is aware of the developmental mechanisms responsible for this transitional stage of lessened or loosened equilibrium. The three-year-old is in much better control of himself. His behavior is more predictable, more amenable. He has attained more power in judging and choosing between two rival alternatives. He does not insist on rituals to protect himself. It is possible to bargain with a three-year-old because he has a more balanced comprehension of two sides of a transaction. He has more flexible interpersonal relations, not only because he has had more experience but also because his action system is for the time being in a more mature and better working equilibrium. The foregoing comparison will serve as an illustration of the kind of ontogenetic shifts in emphasis and balance which constantly recur

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throughout the cycle of growth. This shifting imparts a spiral-like recurrence and reorganization with regroupings at ascending maturity levels. Viewed in perspective, however, the onward advance of maturity traits becomes apparent. At three and a half years of age, there is a return to some of the bipolar characteristics of the twoand-a-half-year-old period, but on a higher level. It is not a regression but another lessening of equilibrium which expresses itself in a transient instability and tentativeness. The four-year-old is in an expansive phase of development manifested in bragging, boasting, and a tendency toward out-of-bounds behavior. The five-year-old is more self-contained, better integrated. He takes himself and others more for granted. He invites and accepts supervision. His ready obedience makes this period of relative equilibrium seem like a golden age. But at six years of age and earlier, the self-containedness gives way to new developmental symptoms. The child's behavior becomes at times brash and combative, as though he were at war with himself and the world. He is indecisive, overdemanding, and explosive; he is also at other times engaging and companionable. He has strangely contradictory spurts of affection and antagonism. These characteristics naturally vary from child to child, but they occur with sufficient frequency and intensity to warrant the conclusion that the period of second dentition is one of great complexity in the ontogenetic organization of the maturing individual. In many respects the behavior symptoms at this stage are reminiscent of the two-and-a-half-year-old transitional disequilibrium. There is an increase of somatic complaints; the mucous membranes become more vulnerable, allergy responses are high, motor adjustments are often clumsy and headlong. Such manifestations can scarcely be ascribed to cultural or psychogenic factors. On the contrary, they point to deep-seated maturational mechanisms. Needless to say, these developmental changes do not occur abruptly, but when the successive annual zones are compared with each other as sectors of a cycle, the presence of an underlying embryological process is revealed. At seven years there is a quieting down. The seven-year-old is much less impulsive than he was at six years. He tends to be pensive. In a sensitive manner he seeks friendly relations with his companions and his teacher. He is in an absorptive, assimilative phase. If he is articulate, we may find that in his more subjective moods he has a fear of losing his own identity. He worries that his mother, teacher, and playmates do not like him. He may entertain a strange fear that he is merely an adopted child. He tends to protect himself by withdrawal.

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In mild degree these are relatively normal symptoms at this transitional level of maturity. They reflect the modus operandi of a normal psychological growth process. When the symptoms are extreme and exhibit a marked schizoid trend, which persists at other inappropriate age levels, the behavior may indicate psychopathology. This is mentioned in passing to suggest that child psychiatry must be based upon a knowledge of the normal ontogenic patterning of behavior. The eight-year-old adjusts more robustly to adults and is beginning to look more like one, for there are somatic changes involving his face and facial expression. He is less brooding than at seven, more receptive to the responses of others. He fraternizes readily with his companions, but he watches adults with a new and critical alertness. He resents being treated as a child, wants to be an adult, and wants the adults to be part of his world. He is unquestionably in an expansive phase, which enlarges the interpersonal scope of his self. At nine years the sense of self comes into clearer focus. There is a new kind of self-consciousness, manifested in self-appraisal, in greater self-reliance, but above all in increased power of self-motivation. Typically, a normal nine-year-old wants to succeed; he works hard for a reward; he works to perfect his skills. He tends to be fairminded and responsible. The ten-year-old displays greater self-possession. He takes his tasks and responsibilities more in stride. He can be relaxed and casual as well as alert. His whole organization is less channelized; his attitudes are more flexible; he is more responsive to slight cues. This makes him very receptive to social information, to broadening ideas and prejudices, good and bad. He is capable of loyalties and of hero worship. In a favorable culture, in a favorable family, he takes kindly to liberalizing ideas of social justice and social welfare (8). Ontogenetically speaking, ten, like five, is a nodal age. A typical ten-year-old is in good equilibrium and in good touch with the adult environment. His individuality is now so well defined, and his interpersonal self is so much more mature, that he can be regarded as a pre-adult, although ten years of adolescence lie ahead—a whole decade more oi biological infancy. The Task of a Science of Child Development The child comes by his mind in the same manner in which he comes by his body, that is, through the organizing processes of growth. According to the principle of hierarchical continuity, no sharp lines divide the three major manifestations of the growth com-

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plex: the anatomic, the physiologic, and the behavioral. A comprehensive science of child development would concern itself with all three of these manifestations and aim to bring them into closer correlation. From the standpoint of clinical science, development is a process which yields to objective methods of investigation and diagnosis. The interaction of psychic and somatic factors is recognized. But if the mind as well as the body falls within the scope of preventive medicine and social welfare controls, chief attention must be given to the behavior patterns of the infant. His behavior characteristics constitute the most comprehensive index of his developmental status and of his developmental potentials. The developmental examination of infant behavior can be undertaken with relatively simple techniques. Using the plain appurtenances of a crib, a table surface, and a series of test objects, it is possible to elicit a rich array of behavior patterns which reveal the organization and the integrity of the child's action system. In clinically experienced hands, a behavior examination may serve several functions, as follows: (a) it ascertains stages of maturity and rates of development in various types of infants—normal, subnormal, and atypical; (b) it yields differential diagnosis in relation to normality, mental deficiency, and specific developmental deficits and deviations; (c) it brings to light otherwise concealed neurologic defects and sensory impairments; (d) it helps to define the developmental outlook in infants suffering from various types of handicap—blindness, deafness, endocrine dysfunctions, convulsive disorders, and cerebral palsies —devastating, selective, and mild; (e) it contributes objective information relative to emotional and personality traits of the infant and throws light on parent-child relationships; (f) it implements a periodic type of developmental supervision of normal as well as handicapped children (6). The demands for such supervision will grow more intense with the elaboration of health services already under way. The progress of the life sciences, which deal with the biochemistry, the biophysics, the physiology, and the pathology of growth, will lead to more systematic protection of infant development. The world-wide study of cancer as a form of atypical growth and the brilliant researches of experimental embryology will almost certainly yield important knowledge for the control of normal organic growth. With more knowledge, there will be refinement rather than loss of human values (3). One task of science is to make the nature of human infancy more intelligible. We are still profoundly ignorant of the mechanisms of

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psychological growth. Many of our ideas about child behavior are essentially pre-Darwinian. The concept of evolution as it applies to the race is much more widely appreciated and accepted than the concept of growth as it applies to infant and child. We still approach the problems of child care, child discipline, and even of child education in terms of one-dimensional absolutes without awareness of the added dimension of development. This lack of awareness constitutes a genuine cultural lag. Our culture at present is more rational about the physical universe than it is about children. We freely acknowledge the laws of nuclear energy, the gradients of the spectroscope and of frequency modulation, but we scarcely recognize that the behavior of the growing child is equally subject to laws, to gradients, and to sequences. The race evolved, the child grows. The enormous evolution of the hemispheres of the human brain has made possible the astounding disclosures of modern technology. But the nervous system of the infant of today cannot be dated ahead. It is built on a conservative model which Nature has not discarded—a model determined by genes no less than by culture. A science of child development is needed to clarify the limitations as well as the potentialities of this all-toohuman nervous system under the impacts of a technological culture. The physical consequences of this culture are even now threatening the developmental rights of children and the normal relationships between children and adults. It has been suggested that if science is incapable of developing moral techniques to counteract this threat, "the split in modern culture goes so deep that not only democracy but all civilized values are doomed." Here, then, lies the task of the life sciences. A science of man under heightening social pressures will need to define the mechanisms, the principles, and in some measure the very goals of child life and of family life. Such a science would be instrumental, and in a way even technological, but it would also be humanistic. It would have an integrity of its own and be in itself a value and a creator of humanistic values. At any rate, we cannot conserve the mental health of children, we cannot make democracy a genuine folkway, unless we bring into the homes of the people a developmental philosophy of child care rooted in scientific research. REFERENCES 1. GESELL, A. The method of co-twin control. Science, 1942, 95, 446-48. 2. . (i n collaboration with C. S. Amatruda). The embryology of behavior. New York: Harper & Bros., 1945.

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3. GESELL, A. Studies in child development. New York: Harper & Bros., 1948. 4. . The Yale films of child development. Yale Sci. Mag., 1950, Nov., pp. 7 ff. 5. . Infant development: the embryology of behavior in pictorial outline. New York: Harper & Bros., 1952. 6. GESELL, A., and AMATRUDA, C. S. Developmental diagnosis: normal and abnormal child development; clinical methods and pediatric applications (2d ed.). New York: Paul B. Hoeber, Inc., Medical Book Department of Harper & Bros., 1947. 7. GESELL, A., and AMES, L. B. The ontogenetic organization of prone behavior in human infancy. /. genet. Psychol., 1940, 56, 247-63. 8. GESELL, A., and ILG, F. L. Infant and child in the culture of today: the guidance of development in home and nursery school. New York: Harper & Bros., 1942. 9. . The child from five to ten. New York: Harper & Bros., 1946. 10. GESELL, A., ILG, F. L., and BULLIS, G. E. Vision: its development in infant and child. New York: Paul B. Hoeber, Inc., Medical Book Department of Harper & Bros., 1949. 11. GESELL, A., and OTHERS. An atlas of infant behavior: a systematic delineation of the forms and early growth of human behavior patterns. 2 vols. New Haven, Conn.: Yale University Press, 1934. 12. HEUSER, C. H. A presomite human embryo with a definite chorda canal. Contr. Embryol., 1932, 23, Nos. 134-38. 13. HOOKER, D. Reflex activities in the human fetus. In Barker, R. G., Kounin, J. S., and Wright, H. F. (eds.), Child behavior and development. New York: McGraw-Hill Book Co., Inc., 1943. 14. LING, B.-C. A genetic study of sustained visual fixation and associated behavior in the human infant from birth to six months. / . genet. Psychol., 1942, 61, 227-77. 15. MANN, I. C. The development of the human eye. London: Cambridge University Press, 1928. 16. METRAUX, R. W. Speech development of the preschool child. /. Speech and Hearing Disorders (in press). 17. WALL, G. L. The vertebrate eye. Cranbrook Inst. Sci. Bull., 1942, No. 19.

Chapter 5 NEEDS AND DRIVES OF ORGANISMS By ROBERT B. AMMONS,

Ph.D.

Introduction What Are Drives?—The basic problem of behavior theory is the prediction of when an organism will behave and how it will behave. In order to predict what behavior the organism is likely to show, we ordinarily have to know something of its history as well as its structure. History can be guessed at by analyzing the results of interviews in the case of humans, but animals other than man cannot talk. In any case, a far more accurate picture of how an animal (human or otherwise) will behave can ordinarily be obtained by creating "history" deliberately, i.e., by observing changes of behavior in an experimental situation, and then reasoning by analogy to other individuals and other circumstances. As we observe successive responses in a situation which is objectively pretty nearly "the same" from time to time, behavior tends to stabilize into a fairly uniform pattern. We say that learning of some kind has taken place. But the mere fact that a relatively stable behavior pattern seems to have been set up is no guarantee that it will appear on the next occasion which looks the same to us, as observers. Just because we present the "same" infant with the "same" bottle of milk at the "same" time in the morning, he does not necessarily nurse in the "same" way or at all. He may merely go back to sleep. The learned behavior pattern must be activated somehow. Hunger activates the behavior. Hunger is a drive. Drives activate behavior patterns and thus to a considerable degree determine when behavior will take place. That they do much more than this will become apparent as we study examples of more complex behavior and other drives such as thirst, pain, social conformity, patriotism, and so forth. What Are the Characteristics of Drives?—Perhaps the best way to begin an analysis of drives is with an example. The ten-day-old infant is awake, although it is only six o'clock in the morning. He is 75

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crying, and the father guesses that the infant is hungry. He gently pushes the mother out of bed, then goes back to sleep. The mother warms a bottle and feeds and rediapers the baby, who then lies wriggling in a rather undirected, undifferentiated way. A diaper pin has been left open and movement works it well through the baby's skin. Crying begins again, accompanied by more vigorous but still undirected movements. Mother picks up baby and sticks herself with the pin in the course of handling him. She exclaims sharply, then quickly locates the pin and closes it, at the same time cooing apologetically to baby. Consideration reveals that the following drives are probably operating : hunger, sleep or rest, desire to avoid argument, activity, pain, and desire to be a "good" mother. Closer study of the example discloses certain definite characteristics of drives. DRIVES HAVE AN ORGANIC BASIS. At least some of the drives have a definite identifiable organic basis. Hunger is associated with blood changes and vigorous contractions of the stomach. Pain results from actual damage to tissue. Drives which have a direct, easily identifiable organic basis have been called organic or primary drives. It is obvious that this can only be a distinction of degree, since all behavior and psychological process must have some organic basis. DRIVES VARY IN STRENGTH. Introspective and behavioral evidence indicates that drives vary greatly in strength. Although the mother may be hungry herself, her drive to feed the baby ordinarily is stronger, that is, is responded to first. Although you are hungry, you "forget" your hunger, at least temporarily, if you put your hand on a hot stove. Methods for comparing the strengths of the various drives in animals and men will be described later in this chapter. DRIVES RELEASE ENERGY. The infant's hunger and the mother's pain both lead to increased activity and energy expenditure. The release of energy is at least to some extent proportional to the strength of the drive, and to the availability to the organism through inheritance or learning of a response to reduce the drive. DRIVES LEAD TO LEARNING. The infant cries loudly and shows increased but uncoordinated muscular activity in response to hunger or to the pain from the pinprick. His mother has learned to obtain food for herself when she is hungry, and to remove from her skin a pin which is sticking her or remove herself from the vicinity of the pin. The behavior which is learned ordinarily is behavior which decreases the drive. Another way to look at this characteristic of drives

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is to say that drives become cues for behavior patterns. That is, they not only activate the patterns, but they even provide the signal which sets a particular pattern going. DRIVES A R E AFFECTED BY EXPERIENCE. A S the infant grows older, he learns ways of obtaining food other than by crying. Comparison of infant and adult suggests that the magnitude of the drive may well be decreased by this learning of drive-reducing responses. Hunger appears to disturb the infant far more than the adult. Experience also seems to produce new and different drives. In addition to the obvious organic or primary drives, there are many drives growing out of experience. The mother's drive to feed a crying infant was definitely not identifiable when she herself was an infant. Such learned drives have been called social or secondary drives. SEVERAL DRIVES C A N LEAD TO OR B E DECREASED BY T H E SAME BEHAVIOR. The mother gets up to feed her child because she is an-

noyed by his crying, is concerned as to the father's irritation at being awakened, is afraid of what the neighbors will say if she doesn't, is afraid the child will not gain weight and she will be criticized by the pediatrician, enjoys holding the child when he is feeding, is thus able to avoid her husband's sexual advances when he awakens, or feels happy to see the child contentedly full of food. Most likely, several of these motives are present. Adult behavior which is not motivated by an obvious organic drive is ordinarily activated by a complex pattern of secondary or learned drives. Of course, drives have many more characteristics than the ones we have just considered, although these are probably the most important. As a rule, drives signal imbalances in the organism or in its relationship to its environment which may disturb the organism's functioning or even threaten its continued existence as an organism. The general balancing process at an organic level is commonly called homeostasis. Homeostasis—Cannon (5) originally used the word "homeostasis" to designate a tendency to steady states in the organism maintained by coordinated physiological processes. He and others have used the term to describe such findings as decreased blood coagulation time after hemorrhage. Many physiological processes associated with homeostasis have not been considered to produce drives. On the other hand, all drives certainly have homeostatic significance. Extensive tissue damage is accompanied by a sensation of pain in the conscious organism. Pain as a rule leads to the learning of behavior which minimizes further tissue damage. In a broad sense

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then, learning is a homeostatic mechanism, and is closely related to drives, as already noted. However, to place drives in a suitable perspective as a part of an organism-environment matrix, a much more general approach is called for, such as that used in psychological field theory. Drive as a Discriminable Imbalance in the Organism-Environment Field.—Field theory originally was developed to account for phenomena of electricity and magnetism as studied by physicists. One of its fundamental principles is that every part of the field influences and is influenced by every other part. A useful application of the field concept can be made to the problem of organism-environment interaction. We can describe all phenomena within and between organisms and environment as taking place in one large field. With this scheme in mind, we can say, at least for the human, that drives are those imbalances in the field which as a rule can be discriminated or identified perceptually. Lowered blood count and hunger contractions both represent imbalances in the total field, but hunger contractions are considered as a drive component, while lowered blood count is not. The hunger contractions can be directly perceived. The concept of field is related to the concept of homeostasis.

Drives So far we have simply attempted to identify and define drives in a common-sense way. We can now discuss what is known about drives and behavior closely connected with them. The available material can be considered under the main headings of primary drives, secondary drives, special problems involving drives, and drive theories. Primary drives are drives which are not learned and have a relatively easily identifiable organic basis. Secondary drives are drives which are learned, are ordinarily of social importance, and have a much less obvious organic basis. There are several special problems concerning drives which merit separate discussion, such as the relation of language to drives and the place of drives in conflict and neurosis. Primary Drives—Traditionally the following needs or drives have been considered to be primary: hunger, thirst, sex, pain, activity, maintenance of body temperature, elimination, sufficient oxygen, and rest and sleep. Most of these have fairly obvious organic bases, although there can be no sharp line drawn between primary and secondary drives on this basis. Primary drives are associated with

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organism-environment imbalances which eventually must be corrected if the organism is to continue to function. The structural basis for the primary drives has been developed in the course of evolution and tends to maximize survival. These drives form part of a whole hierarchy of drives, which includes learned or secondary drives as well. In situations where both primary and secondary drives are present in full or nearly full strength, the primary drives tend to dominate in the sense that behavior appropriate to their reduction is elicited. Thus the desperately hungry and thirsty flier, when rescued after being adrift on the ocean for many days, will disregard social convention about eating, and even his own knowledge that he will probably make himself sick, in trying to overcome the deficit as quickly as possible. Hungry men will kill to obtain food, and sex-starved men will rape or become overtly homosexual in attempting to satisfy their need. Primary drives are variable in strength within and among individuals. Within a given organism each drive tends to fluctuate in strength and to become relatively stronger or weaker than other drives. At one time hunger may predominate, while at another time thirst or need to eliminate may be prepotent. A need can be forced out of consciousness, as when, for example, you ignore the pain from a headache. It appears that the average strength of drive in different individuals is not the same, some being much more "driven" than others, and the pattern of relative drive strength also differs from individual to individual. Some are more driven by pain, others by hunger, and so forth. Primary drives interact in various ways with secondary drives, producing even more complex patterns, one dominating the other. Witness the child in whom need to micturate becomes stronger than need for social approval, with the resulting wet spot in the middle of the front-room rug. In the nonhuman animal there are probably a good many more unelaborated primary drives in evidence than in the human, since animals inherit many more tendencies to specific behavior patterns. Such behaviors as nest-building, migration, homing, and hibernation seem to provide the basis for specific drives in animals. Having considered some of the more important properties of primary drives, we are now ready to discuss several of those drives in greater detail. H U N G E R . When the stomach is empty, or nearly so, and blood sugar has fallen below a certain level, we may begin to feel hungry.

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We are aware of hunger pangs, first weak, then gradually increasing in strength, coming a minute or two apart. To find out the nature of these pangs, Cannon and Washburn (7) studied stomach activity directly with X rays and indirectly with pneumographic recording. In the latter case, the subject swallowed a balloon with a tube attached to it. Then the balloon was inflated, and changes in pressure were recorded. Subjects were instructed to give a signal each time they felt a hunger pang. In this way, a simultaneous record was obtained of actual stomach contractions and reported pangs, and it was apparent that the pangs were sensations arising from the contractions. The X-ray studies showed the same thing. Investigators suspected that there was more to the hunger drive than stomach contractions. Observations were made on a patient whose stomach had been removed, his intestine and esophagus being joined. On recovery he ate normally and stated that he felt about his usual desire for food. Of course, nothing much is demonstrated conclusively by one case. However, experimental check on the relation of the stomach to hunger drive is quite possible. Tsang (29) removed rats' stomachs; then, after they had recovered, he observed their behavior in a variety of situations. When deprived of food and compared with normal rats who still had their stomachs, these stomachless rats were initially just about as well motivated, as evidenced by high efficiency in running a maze. However, even a small consumption of food decreased motivation markedly. The effects of the hunger drive on general activity were great. There was about three times as much activity in the hour before feeding as in the hour after feeding. Bash (3) surgically isolated rats' stomachs from the central nervous system, leaving them otherwise intact. He found that frequency of eating was about the same as in normal animals. Learning of a simple maze was at about the same rate. Bash concluded that at least under certain conditions, after gastric sensations have been eliminated, the hunger drive is kept at almost full strength by some sort of biological process. The various investigations seem to show that although hunger and stomach contractions are related, stimulation from the stomach and even presence of the stomach itself are not necessary conditions for the existence of an essentially normal hunger drive. These studies have dealt primarily with generalized hunger. A different approach has been made by persons interested in the drive values of various kinds of food. The human often experiences a

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heightened desire for one or another food, as witness the pregnant woman eating a pint of pickles at one sitting. Some of the strength of the craving doubtless derives from learning experiences, but it is quite possible that there is a real organic basis. When experiential factors are nearly or completely ruled out in animals or infants, hunger appears to be an adequate guide to a balanced diet. Evvard (9) allowed pigs to choose their own diets from among shelled corn, whole oats, linseed oil meal, meat meal, limestone, charcoal, and common salt, all made freely available. He found that the animals equaled or bettered the growth records of pigs fed with a single ration selected by a grower. Richter and his coworkers (24) presented rats with a variety of foods in aqueous solution. The amount of each food eaten each day was calculated, and the choices were quite adequate to meet the requirements of normal growth and reproduction. Interestingly enough, there was less food intake than with a standard mixed diet, a fact that has been interpreted to mean that animals may eat to excess to obtain necessary amounts of certain foods. Studies of infant self-feeding have shown that even humans are capable of adequate choice of foods. Although there are marked changes in preferences from time to time, unpredictable by the observer, the over-all average intake amounts to a balanced diet. Of course, if you punish your child severely for not eating vegetables, this is likely to complicate the natural selection process. A whole series of studies have shown that organisms tend to eat in a compensatory way, that is, to obtain foods which satisfy certain definite needs. When animals have been fed a diet deficient in protein over a period of time and are then allowed to choose between a high-protein and a low-protein diet, they regularly choose the former. The same seems to hold true for at least some of the B-complex vitamins. During pregnancy, rats tend to increase their intake of calcium, phosphorus, sodium, fats, and proteins, a change which reflects changing metabolic needs quite faithfully. When the parathyroid glands are removed from rats, there is a large increase in the rate of calcium excretion and hence a need for a greater calcium intake. This need is reflected in changed eating behavior. For example, a strong preference for water containing calcium lactate develops, and calcium intake becomes many times greater than that of normal controls. When a functional graft of parathyroid tissue is made, calcium excretion decreases and there is a corresponding decrease in intake. Removal of the pancreatic gland should lead

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to diabetic symptoms. However, pancreatectomized rats do not ordinarily develop these symptoms, but they do show definite compensatory changes in eating behavior. There is an increase in consumption of olive oil, which the animal can still utilize, while sucrose consumption decreases to a very low level. Sheep fed a diet deficient in minerals and vitamins often develop a wool-eating habit. A particularly interesting example of compensatory hunger is osteophagia in cattle whose diet is deficient in phosphorus. These cattle search for and eat bones—the greater the deficiency the "greener" the bones accepted. Although there is much experimental and observational evidence that actual bodily deficiencies in quantity and kind of material lead to hunger, we must not forget that, except in the very young animal, these hungers are overlaid and influenced by behavior and hunger drives due to learning. The older adult tends to eat inefficiently and too much, mainly because of previous experience. As a child, his energy requirements were great and huge quantities of sugar could be handled well, hence eating of much candy and dessert was functionally desirable. Over-all food requirements were greater and so eating large amounts of food was rewarding. If you were physically forced to eat salads and green vegetables as a child, the chances are that you eat too little of these foods as an adult. THIRST. Casual introspection when one is thirsty leads to the conclusion that the thirst drive is due to dryness of the mucous membrane of mouth and pharynx. Up until fairly recently, this explanation was accepted without much question. Cannon (6) developed a "local theory" of thirst incorporating this dryness of mucous membrane as a primary factor. He proposed that a lowering of the amount of water in the blood leads to a compensating decrease in the amount of water in the tissues. Decrease of water in tissues means decrease of water in salivary glands, and decrease of water in salivary glands leads to decreased secretion of these glands. Decreased secretion means that the membrane becomes dry more easily, and hence we experience thirst. Several lines of evidence seem to support this view. One would predict that experimental procedures decreasing salivary gland secretion should lead to sensations of thirst, which are semi-independent of the condition of the blood and the rest of the body. When a subject is placed in a very dry room, he tends to feel thirsty before body water content is appreciably affected. Injection of atropine or painting with cocaine also inhibits salivation and leads to sensations of thirst. When salivation is interfered with by tying off or partially extir-

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pating the salivary glands, dogs drink more often. This increased frequency of drinking was also observed in the case of a man with congenital absence of the salivary glands. Unfortunately for those who would like to account for thirst drive and water intake in such relatively simple terms, the local theory does not account for many important facts. For example, the man without salivary glands drank more frequently, but his total intake of water was about the same as other peoples'. The dogs with decreased salivation also drank more frequently, but their water intake was about the same as that of normal dogs. Even partial denervation of mouth and throat did not seem to affect total intake. In short, factors other than mucosal dryness must play an important role in the thirst drive. Several experiments throw light on the mechanisms involved. Robinson and Adolph (25) found that drinking behavior in dogs appeared when they had lost less than 1 per cent of their body weight of water. Adolph ( 1 ) and Bellows (4) review work on the relationship of water ingestion to water deficit. Dogs drank very nearly the amount of water necessary to make up for the deficit developed during a period of deprivation. When the esophagus was operatively altered so that water could not get to the stomach, it was possible to measure this same relationship. Again, amount of water taken in was proportional to deficit. It is apparent that the thirst drive is dependent primarily on water deficit in the body. Introspective reports relate it to dryness of mouth and throat. Experiments show that induced dryness increases frequency of drinking, but does not have much effect on total water intake. On the other hand, the greater the deficit, the dryer the throat and the greater the thirst. It is quite probable that the close relationship between deficit and intake at a given time can be accounted for by learning. SEX. Even more than in the case of most of the other primary drives, study of the sex drive is made difficult by learning. The sex drive is perhaps more interesting than most because facts about it are hidden, suppressed, and consciously or unconsciously distorted. At least up until the time of Kinsey's reports, the average adult was not aware of the existence of usable statistics concerning the sex drive, much less their scientific implications. Actually this knowledge is very extensive and covers most of or all the general aspects of the sex drive and related behavior fairly adequately. In this section we will discuss the physiological foundations and the complex behavioral manifestations of the sex drive in animals and man.

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A great deal of information is available about the physiological foundations of sex behavior in animals. Fortunately or unfortunately, we cannot experiment freely with human beings, but we can with animals. In female rats there is a considerable increase in total activity from the twenty-first to the seventy-fifth day of life (30), corresponding in part to the physical change from infancy to sexual maturity. More interesting perhaps, and certainly more important to the study of sex drive, is the change in the pattern of activity. As the rat becomes older, instead of rather irregular fluctuations from day to day in activity, with relative stability, there develops a rhythm in activity, corresponding apparently to stages in the oestrus cycle. For a few hours while in oestrus, the females are very active, then activity drops off sharply until they are next in oestrus. In the normal adult female, these cycles are four or five days in duration (23). During pregnancy, the cycle is suppressed, but it reappears after weaning of the young. The cycle also disappears after ovariectomy, but it can be reinstated by injection of sex hormone or by successful transplantation of ovarian tissue. The male rat shows similar behavioral changes (23) although no particular periodicity is identifiable. When the adult male is castrated, his activity drops to a very low level and tends to stay there. Injections of sex hormone or gonadal implantation restore the activity to somewhere near its original level. This is true even when ovaries are grafted in a male animal. When injections are stopped or implants removed, activity level drops again. We should be very careful not to conclude too much from this kind of study of glandular removal. It must always be remembered that any changes observed may well be due, not directly to loss of the gland's secretions, but indirectly to the effect of this loss on other glands and the changes in these glands and their secretions. Effects of satiation of the sex drive have been observed rather carefully in rats (31). After a two-hour copulation period, each animal was given a twenty-minute test period to see how many times he was willing to approach, contact, and cross a charged grid to reach a receptive female. Each male was tested at only one interval after satiation. Tests were made on different groups of animals after no, six, and twelve hours and one, four, seven, and twenty-eight days from the time of satiation. In terms of number of crossings of the grid, recovery progressed rapidly, being complete after one dayControl animals, given an opportunity to cross the grid in the absence of female incentive, crossed it much less often than the experimental animals.

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Although we have no similar reliable, objective information as to the rate of recovery from sexual satiation in the human male, we do have considerable data on effects of castration. In the main, males who have been castrated show a sexual decline. However, in a review of the literature, Tauber (27) reported that in many men sexual behavior remains unchanged, and, in a few cases, the drive may even be increased. There is obviously a large psychic effect in cases such as this. There are many instances of accidental castration during war where potency and libido have been retained. Ovariectomized females usually show a gradual loss of sex drive and report a decrease in pleasure from coitus. In both males and females, replacement hormone therapy may restore the sex drive to somewhere near what it was originally. Let us turn now from more obviously physiological factors affecting the sex drive to review of some of its complex behavioral manifestations. The animal behavior to be discussed is copulation and the relation between timidity and sexual potency. In rats, as a rule, copulation takes place only with a female in heat, although highly excitable males may make attempts with nonreceptive females and respond to young guinea pigs. Copulative behavior appears at an age of about fifty days in both males and females, and the pattern of behavior seems to be well developed. Young males kept isolated from the time of weaning perform adequately at the first opportunity. In higher animals, less of the copulative pattern seems to be inherited, and copulation is less governed by the oestrus cycle. Many studies of apes have shown mating to take place relatively independently of the cycle, while others have shown a relation between the two. Yerkes (33) observed that activity of experienced, congenial mates was likely to be restricted to the period of swelling in the female. The picture is complicated by social factors, since in the case of some unfavorably mated animals, the female apparently disregarded menstrual phase and offered herself to the male as a friendly gesture. One can measure the timidity of rats in terms of amount of defecation in a novel situation. Several studies have been made to determine relationships between the sex drive and timidity. It was found that male rats which were more potent sexually were less timid, and a corresponding relationship held for females. It was also noticed that females were less timid than males. Of particular interest to the medical practitioner are the results of investigations of human sex behavior at various levels of maturity. It is plain that the child comes into the world equipped with sex organs. The child not only has sex organs, but he also apparently

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experiences an appreciable sex drive. Halverson (10) observed penile tumescence and detumescence in male infants ranging in age from three to twenty weeks. Observations were made eight and a half hours a day for ten days. Tumescence typically occurred at least once a day, and in most cases it occurred more than four times. It lasted 2.4 to 14.5 minutes on the average and often awakened the infant from sleep. In most cases it was accompanied by restlessness, crying, fretting, stretching, or flexing the legs with considerable tension. In contrast to this, detumescence did not often disturb sleep, and seemed to be accompanied by relaxation. We can infer that there are definite feelings of pleasantness and unpleasantness, although of course the infant cannot give a verbal report of his experiences. Psychoanalysts maintain that the infant and child experience diffuse sex feelings or drives. Retrospective reports in the clinical situation often contain information of this kind. Kinsey's (16) male sample reports a good deal of sex behavior prior to adolescence. By the age of ten at least a third had participated in some definite sort of sex play, and this was true of 10 per cent even by the age of five. At least a tenth had practiced coitus by the age of ten. Many preadolescent boys reported being aroused sexually by seeing or thinking about females, hearing or telling sex jokes, and seeing sex pictures. Orgasm was actually reported as observed in boys as early as five months. By the age of five years, 10 per cent had experienced orgasm, and by the age of ten years, over 60 per cent. It must be clear that the sex drive appears early in the human, and behavior to satisfy it is soon acquired. The myth of the nonsexual child has been exploded, and a more realistic attitude toward sexually driven behavior in infancy and childhood can be developed. First ejaculation occurs normally at puberty. After their first ejaculation experience, almost all males adopt a regular routine of sexual activity within a year or less. Kinsey (16) found that mean frequency of sexual outlet per week is nearly as high at age fifteen as at any later age, although of course there are changes in type of outlet. Mean frequency remains at a high level until age thirty, then declines steadily. However, even into the seventies, there is an appreciable frequency. Kinsey's figures on erectile impotence show that at the age of eighty there are still some males who are sexually potent. As the menstrual rhythm becomes established in girls, definite physiological changes take place. However, because of the deep overlay of learning, few corresponding changes appear in behavior. The

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performance of brief, relatively easy tasks such as tapping and colornaming does not show fluctuations attributable to the menstrual cycle. More complex tasks, such as maze learning and choice reaction time, also show no cyclic improvement or impairment. A different approach to the sex drive in human females, and seemingly a more direct one, is to have married women rate their sex feelings repeatedly and then compare these ratings with the menstrual cycle. Whereas the female rat is receptive only when in heat, and the ape primarily then, there is such a difference between human females in rated sex drive that little can be concluded. Some women are more driven during menstruation, others midway between periods. Psychological factors are overwhelmingly important. We have spent a good deal of space considering the sex drive. It is not the strongest of the drives, and its satisfaction is not necessary for the survival of a given individual. Why is it so important to our society ? Perhaps because we have not accepted it as a normal primary drive and treated it as such. PAIN. There is no doubt in your mind just after you have slammed a door on your finger that you don't want to do it again. You do not learn to feel pain, although learning may play an important part in determining your response to it. The drive to avoid pain is strong. Pain is felt when there is appreciable tissue damage and the nerve pathway to the central nervous system is not blocked by unconsciousness, anesthesia, or actual destruction of nervous tissue. Its function is an important one to the survival of the organism, since, if damage and injury were not signaled, response would not be made and life would certainly be shorter. Pain can be aroused by electrical, thermal, chemical, and mechanical stimuli. Mechanical stimuli produce a sensation of pressure, and to produce pain they must be quite strong. Chemicals injected into tissue can produce pain, especially in the case of acids. Extremes of temperature can be painful. Heat is often produced experimentally by focusing infrared rays on the skin with a lens. The best-controlled method of eliciting pain is with an electric spark. The stimulated area is very small, and no real damage is done. When the skin is stimulated locally, pain receptors seem to have a punctiform distribution and are not evenly distributed. More spots are found on the volar side of the forearm and the chest than on the ball of the thumb and the tip of the nose. The pain threshold is much lower for the cornea and conjunctiva than for the sole of the foot, the calf of the leg, or the back of the hand. The visceral organs are less

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sensitive to pain stimuli than is the peritoneum. In general, sensitivity to pain is a function of number of pain spots and thickness of skin or protective covering. Pain from arthritis and cancer does not seem to show adaptation, that is, there is no apparent decrease with continued stimulation. On the other hand, pain from a needle pressed into the skin with a steady force tends to decrease noticeably with passage of time, as does pain from radiant heat. Stimuli which are sufficient to produce a sensation of pain in an adult do not necessarily produce this sensation in the fetus and newborn, which are relatively insensitive. Pain is not felt by some adults, who apparently lack the necessary neural structures. Two different sorts of pain have been identified introspectively, a quick, sharp, "prick" pain, and a slower, dull, longer-lasting pain. It has been suggested that these are correlated with different types of nerve fibers. Two principal theories of the physical nature of pain have been advanced. One states that pain is simply due to excessive stimulation of any kind and is mediated by any sensory nerve. The other proposes that there are special pain receptors. Neither theory accounts for all the facts, but the special-receptor formulation seems to account for more of them. ELIMINATION. The normal organism must excrete waste products from its body. In higher animals and man, this is partially accomplished by urination and defecation. Materials accumulate in bladder and colon until a stimulation threshold is reached, when they are released. Thus, we find a cycle or rhythm in elimination. In adult rats, defecation has been observed to take place at something like five-hour intervals, while urination is observed at two-hour periods. In humans, durations of these cycles are variable and greatly affected by learning. Urination may take place at intervals as short as a few minutes or as long as days. Defecation may take place only once in several days, or much more frequently. Certain apparently unlearned behavior patterns associated with elimination can be observed in cats and dogs. A particular environment is required, and attempts are often made to cover the excrement. Observations have been made of an interesting relationship between hormones and urination behavior in dogs. Normal females squat while urinating, while males raise a hind leg. Males which have been castrated early in life do not develop this leg-raising behavior unless injected with male hormones. Females spayed at an early age and treated with androgen will often show leg-raising behavior.

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The influence of learning on human excretory behavior is very great. The infant is born without voluntary control of sphincters and with a capacity for enjoying the processes of excretion. Society demands control, and so a conflict often starts between parent and child. Put on the toilet, the child may sit for half an hour without activity, only to defecate promptly on the front-room floor when removed. Feces are withheld or expelled violently. Excretion becomes in many cases the basis for emotional interactions between child and parent, and usually unpleasant ones. It is interesting to note that enuresis is practically always psychogenic, and that incontinence in children is very often not due primarily to organic anomalies, but to learning. A simple check on this is the number of cases where difficulties remain even though the apparent organic bases of the behavior are removed. OBTAINING OXYGEN AND RELEASING CARBON DIOXIDE.

The

need or drive for oxygen, along with the remainder of the primary drives discussed in this chapter, is not as specifically signaled as are pain and thirst. The strength of the drive for air is perhaps not as apparent as the strength of some other drives, but anyone who has been temporarily deprived of air by obstruction of the windpipe can testify to its potential strength. The drowning man forgets everything in his attempt to reach air, and his struggles may lead to painful injuries to various parts of his body, which injuries he may not notice at all at the time. Hold your breath as long as you can and observe the growing strength of the desire to breathe. On the other hand, at high altitudes, a person may actually become unconscious without realizing his oxygen deficit. When the tissues need more oxygen, this need is ordinarily accompanied by pH changes due to increased amounts of carbon dioxide or lactic acid in the blood. Increased body acidity leads to an increased breathing rate, which brings more oxygen into the lungs and makes possible more rapid loss of carbon dioxide. The actual physiological mechanisms regulating breathing are very complex. ACTIVITY. Some students of behavior have proposed that the need for activity should be considered as primary to the organism. It is certainly true that physical condition is often poor when little muscular activity is possible. In any case, the animal which was not aroused to greater activity by such drives as hunger, thirst, and sex would be a bad bet for survival in the evolutionary process. We do have a good deal of data concerning activity cycles, some of which have already been summarized in the discussion of other drives.

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Increased activity precedes or accompanies periods of gastric motility and of heat in the female, and it is elicited by pain and excessive stimulation. Activity level varies with light and darkness (70 per cent of rat activity is in the dark), temperature, and season of the year. Activity usually decreases after castration and thyroidectomy, but increases in some cases after removal of the prefrontal areas of the brain. BODY TEMPERATURE. There is a need in warm-blooded animals to maintain a certain body temperature. A great deal of man's behavior is designed to obtain and keep shelter from the cold of winter and the heat of summer. Fluctuation of body temperature a few degrees up or down can have dire consequences, so a complex regulatory mechanism has been developed to maintain nearly constant body temperature. When it becomes necessary for the body to lose heat, there is vasodilation, increased perspiration, speeded-up respiration, and lowered oxygen metabolism, most of which changes are due to hypothalamic control. When the external temperature is low, there are many compensatory changes, such as increased metabolic rate, faster heartbeat, shivering, constriction of superficial blood vessels, and even choice of high-calory diet. Of course there will also be overt activity directed toward changing the external conditions. In lower animals, there are often unlearned behavior patterns which are set off by excessive heat or cold. Kinder (15) studied nest-building in rats by observing the number of strips of paper used during a given time. She found that the size of the nest was closely correlated with temperature; the colder it was, the bigger the nest constructed. REST AND SLEEP. Although not necessarily produced by the same experiences and conditions, the needs for rest and sleep are sufficiently similar to be considered together. Continued activity of any kind eventually leads to a desire for cessation and rest. Everyone has had the experience of walking or playing a game until he is so tired he would gladly collapse on the spot and go to sleep. Anyone who has driven a car without stopping for many hours at high speed or over a poor road has experienced an intense desire to rest or sleep. Many studies have shown that, in general, prolonged loss of sleep has a bad physical effect, although some organisms can survive with much less sleep than others. Sleep in man can be characterized as a condition in which there is a loss of consciousness without loss of ability to regain consciousness

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when strongly stimulated. During sleep bodily activity decreases to a relatively low level and reflex thresholds are much higher. Johnson and associates (12) found that people move frequently in their sleep with an average period of rest of only a little over ten minutes. Individuals vary, making from twenty to sixty major movements in one night. Depth of sleep changes from time to time. Kleitman (17) found that, in general, the longer a person had slept, the shallower was his sleep, and the shorter the periods of relatively deep sleep. Need for rest tends to change in proportion to the effortfulness of the task and the duration and frequency of rest pauses introduced. Fatigue is evidenced by mental "blocks," decreased performance on tasks calling for continuous close attention, and slowness in changing from one activity to another. There has been much speculation over the physiological correlates of sleep and how much sleep is desirable or necessary for continued adequate functioning. This latter problem has seemed particularly important to many generations of students. No really adequate theory of sleep has as yet been proposed. "INSTINCTIVE" OR "INHERITED" BEHAVIOR. In many animals, particularly the lower animals, there are patterns of behavior which seem to be inherited. The animal gives an essentially adequate performance even though it has had no previous practice and may actually have not even had an opportunity to observe another animal engaged in the activity. Migration, maternal behavior, nest-building, and hibernation are all this kind of behavior. Something is known in each case of what sets off the behavior and its physiological basis. Numerous animals migrate, and apparently for various reasons. Birds move north and south with the seasons, often covering great distances. Movement seems to be related to changes in the gonads, brought about by pituitary changes caused by amount of daylight. Studies have shown that newly hatched birds can migrate successfully without any prior experience and without having other birds of the same species to follow. Salmon migrate downstream to the ocean, then after two or three years they migrate upstream, often to the place where they were hatched. Explanations of these migrations have been made in terms of amount of light, water temperature, metabolic changes with sexual maturity, amount of oxygen in the water, and tendency to swim against the current. Many animals care for their young quite adequately without prior learning. Nests are built, and young are cleaned and nursed and are

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brought back to the nest when they are removed or fall out. If disturbed, the female will often move the nest, and even household pets will show aggressive behavior if their young are disturbed. Nestbuilding activity in rats is greater as temperature decreases, declines to its lowest level during oestrus, increases steadily to a high level during pregnancy, and remains high until shortly before the young are weaned. Attempts have been made to account for maternal and nesting behavior in terms of change in hormone balance, stimulation from the young, and learning based upon these. Many mammals hibernate during the winter, usually in places where they are somewhat protected from the cold and other animals. Heart rate drops, metabolism decreases, and body temperature is much lowered. These changes take place only in certain species and seem to be due to endocrine changes with the seasons. Behavior based on all the so-called primary drives can be changed by experience, and possibly even the drives themselves can be modified. In each case, however, there is a more or less well-known specific physiological basis. To some degree, the drives are merely arbitrarily chosen and named aspects of body functioning, often noticed because of the specificity of the behavior they seem to elicit. Our next section will tell about various methods of studying primary drives. Methods of Studying Primary Drives.—We have already had a chance to see something about experimental procedures for manipulating primary drives. It is the purpose of this section to explain some of these procedures in more detail. We can study drives by deliberately and systematically manipulating antecedent conditions, or by measuring outcomes, or both. Change of antecedent conditions is commonly accomplished by varying the energy level of the external stimulus, varying time of deprivation, or by actual organic intervention. The effects of these and other changes on the organism can be studied by means of activity records, chemical tests of body substances, work output measures, obstruction boxes, projective tests, and introspective reports. Change of Antecedent Conditions.—ENERGY LEVEL OF E X Drives can be varied in strength by changing the degree of stimulation. Obvious examples of this involve electric shock, excessive heat, and direct production of pain. Electric shock is the stimulus most often used in this kind of experiment. For example, three groups of human subjects are to learn a stylus maze— a path from one point to another, which they trace with a metalTERNAL STIMULUS.

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tipped pointer or stylus, avoiding blind alleys as much as possible. Learning on successive trials is measured in terms of time to trace through the maze and number of errors, that is, entries into blind alleys. Entry into a blind alley completes an electrical circuit, and the subject is shocked on the hand holding the stylus. Treatment of the three groups varies only with respect to intensity of stimulation, one receiving weak shocks, one strong shocks, and one moderate shocks. Indications from past experiments are that the group receiving the strongest shocks will be the most highly motivated to avoid blind alleys. Rats are often motivated to run by using an electrically charged grill for the floor of the runway. The charge on the grill is varied, and within limits the rat runs faster the greater the shock to his feet. Hull (11) proposes that there is a lawful relationship between stimulus intensity and behavior: "Other things constant, the magnitude of the reaction potential . . . has an increasing monotonic relationship to the intensity . . . of the stimulus in question . . . " T I M E OF DEPRIVATION. The longer (within limits) an organism is deprived of means of satisfying primary drives, the more motivated it will be. Systematic studies have been made of the effects on behavior of depriving organisms of food, water, or sex for increasing periods of time. We have already seen how the sex drive as measured in an obstruction box increases over a deprivation period of twentyfour hours (31). Skinner (26) found that rate of pressing a food lever increases regularly for five days in the case of rats, then drops off. It is quite possible that drive would continue to increase, but rats die of starvation after the sixth day. Perin (22) also studied the relationship between lever-pressing and time of food deprivation. He was interested in how many times a rat would press the lever without receiving a reward before reaching a minimal performance level. There was a regular increase in bar-pressing activity from three hours' hunger through sixteen hours to twenty-three hours. Similar work has been done with thirst. Preference studies with foods show that animals will in many cases increasingly more often choose the food containing a given dietary component as the deficit of that component in their diet is greater. ORGANIC INTERVENTION. Direct manipulation of the body and its chemical processes is possible. The gonads can be removed to determine the effects of sex hormones on behavior. Glands can be implanted. By injecting insulin into the blood stream, the blood sugar level can be manipulated and thus one of the antecedent conditions of

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hunger can be controlled. Injection of sex hormones has been used to increase sex drive, although the psychological component in this case is probably large. It is quite possible that organic intervention will eventually provide the best method of controlling antecedent conditions in studies of primary motivation, although at present the physiology and biochemistry of the body are not well enough known to permit one to be sure of just what ramifications a particular intervention may have. Measuring Outcomes.—The second general approach to the study of primary drives is by way of studying their effects. We can produce or measure changes in antecedent conditions, then observe apparent bodily and behavioral consequences. ACTIVITY RECORDS. The two most widely used methods of studying activity are the activity wheel and the activity cage. The activity wheel is attached to the animal's living quarters. It is so constructed that as the animal runs, the wheel turns under him. A mechanical counter keeps track of the total number of revolutions and can be read as frequently as desired. An activity wheel was used in the studies already cited by Wang (30) and Richter (23) of the relationship between sex drive and activity level. A simliar device, the treadmill, has been used extensively with humans. The person being tested walks along a pathway which consists of a sort of endless belt which moves under him as he stays in one spot. The belt can be moved by the subject's efforts alone, or he can be paced by running the path past him with a motor. The difficulty of the task can be varied by changing the slope of the path, causing it to move more rapidly, or making it harder for the subject to make it move. The activity cage is ordinarily a cage suspended on three springs or solenoids. A record is kept of changes in the balance of the cage, which record of course reflects activity by the animal within the cage as its weight is shifted. A comparable piece of apparatus has been used to study the movements of humans during sleep. If a continuous record is kept, it is possible in both cases, to determine the magnitude of movements and when they take place. CHEMICAL TESTS. TO the extent that we accept the assumption that motivation is related to body changes, we should be able to some degree to measure motivation level by chemical tests. Below-normal blood sugar could be used to indicate hunger. Absence of estrogens and androgens could indicate lack of sex drive. Lowered tissue water content might serve as an index of thirst Fatigue could be esti-

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mated in terms of amount of carbon dioxide and lactic acid in the blood. W O R K O U T P U T . The more highly motivated the individual, the more work he is likely to do in a given time. W e have already mentioned one instance of this in the case of activity measures and the treadmill. Skinner's (26) work with rats indicates that when other variables such as expectancy are held constant, the greater the drive, the more rapid the performance at lever-pressing. In studying a simple motor skill (rotary pursuit) in humans, Kimble (14) found evidence that was consistent with the hypothesis that the greater the motivation, the greater the amount of reactive inhibition or work decrement a subject would tolerate. The various incentive systems adopted by industry are based upon findings that under many circumstances more work is done if the motivation is higher.

OBSTRUCTION BOX. A simple way to compare the strengths of two drives is to arrange a situation in which the drives call for incompatible behaviors, and then observe which behavior takes place, and in what proportion of the instances of testing. In the obstruction box, the rat has to cross a grid to reach something needed to reduce a drive, such as food or water. The drive to avoid pain is thus set against the hunger or thirst drive. Tsai (28) used a modification of this technique to compare the hunger and sex drives in rats. He used an apparatus with two alleys, one leading to food, the other to a receptive female. After an animal had been given experience in both alleys, he was deprived of food and female companionship for a given time, then allowed to choose between the two alleys. Under these circumstances, Tsai's rats chose food much more often. Warden (31, 32) compared the strengths of several drives using the obstruction box, and found that, at least for the conditions he used, the maternal drive was strongest, then followed thirst, hunger, sex, and exploratory drives. The relative positions tended to change somewhat when the comparisons were made after varying periods of deprivation. PROJECTIVE T E S T S . Many years ago it was noticed that, when a person was hungry, he often saw ink blots or cloud pictures as pictures of food. Recently a number of studies have been made with ambiguous pictures. In one of these, McClelland and Atkinson (18) tested subjects after food deprivations of approximately one, four, and sixteen hours. Subjects were shown blank slides at very low light intensity or slides with smudges and shadows, and were asked questions about what objects were being shown. It was found that frequency

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of food-related responses increased as hours of food deprivation increased, and the increase was mainly in number of instrumental objects (e.g., knives) "seen," rather than in actual food "seen." The Thematic Apperception Test and the Rorschach inkblot test are widely used to study needs and drives of all kinds. INTROSPECTION. AS far back as we have records, we find that men have observed their own drives. Within the last hundred years, the introspective method has been developed into a scientific tool. Although psychologists gradually have come to emphasize the study of publicly observable behavior, introspection is still used. As we noted in discussing hunger, the earliest studies of stomach contractions involved introspective reports of hunger pangs. Most early studies of sensation and perception were based upon introspection. Investigations of pain being conducted at present call for subjects to report which is more severe, a reference pain or the pain being measured. Even McClelland and Atkinson (18) in their studies of food deprivation and projection, asked for subjective ratings of intensity of hunger. It is quite possible that introspection will remain a valuable method for studying drives. Introspection by the experimenter himself, plus reports from subjects, will at least serve as a basis for formulating hypotheses and perhaps as a check on results obtained by other methods of observation.

Secondary Drives.—Secondary drives have also been called learned or social drives. The organism is not born with them, although they probably all have an identifiable organic basis. A whole pattern of behavior may acquire drive properties of this kind; for example, a teen-ager can be rewarded for fast driving by being praised by his companions and then continue to drive fast for many years, even though there is no further reward. Behavior suitable for the acquisition of money can acquire a drive value of its own. Many persons work "for the pleasure of working" or because work "is its own reward." A person who is successful in accumulating a large amount of money may continue to work for more money far past the time when the additional money can have any real value to him. The actual process whereby a secondary drive is set up is fairly simple. Some sort of discriminable pattern of stimulation is consistently associated with reward. After a series of such instances, the stimulus acquires the power of eliciting behavior by itself and even serves to reward the behavior. For example, a rat which has learned to press a lever to obtain food will often continue to press the lever after satiation and will simply allow the food to accumulate without

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eating any. A good illustration of this process can be found in an experiment by Cowles (8). Two chimpanzees were trained to put colored discs into a slot machine to obtain raisins. Then they were given a discrimination problem to learn. If they chose the correct box in a row of five, they found a colored disc. Only after numerous trials, a considerable delay, and in a different room could the chips be used to obtain raisins. The animals showed very definite learning, with only the chips as direct reward. The chips had acquired a drive value of their own. Secondary or acquired drives have a number of characteristics which should be noted: (a) They are often as strong and persistent as primary drives, and, at least in the case of humans, they are sometimes stronger, (b) They are usually object-directed, that is, usually directed toward some object or class of objects. Some are not objectdirected, as for example, free-floating anxiety based upon early experiences, (c) They are probably more variable in strength within and between individuals than are primary drives. This is easy to account for, since they are based on experience, and every individual's experiences are different from every other individual's, (d) They can be repressed and left unsatisfied. Most primary drives must be satisfied if the organism is to stay alive, (e) They are organized into very complex patterns, which can, as a rule, be analyzed only with difficulty and with a certain artificiality, (f) The same object may acquire secondary drive value from several different sources, and a given behavior pattern can be maintained by several different secondary drives in succession, (g) Those set up on the basis of avoidance of noxious stimuli are highly resistant to extinction. A person who has nearly drowned may never again in his lifetime go near any sizable body of water. In general it is apparent that secondary drives serve to help the organism adapt to its environment. They are readily set up and usually rrodifiable. In the human, they are mostly based on language, and hence can be passed on from generation to generation. In this way, the "social inheritance" of drives is achieved. There are myriad secondary drives, and we can discuss only a few of the more important of them in this chapter. IMITATION. T O some extent in lower animals, and certainly in humans, a drive is set up to imitate others. Once such a drive has been established, the process of socialization is greatly simplified. Miller and Dollard (21) have worked out an extensive theory of how a drive to imitate is produced and how it affects social behavior.

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Carefully controlled experiments were conducted with rats. Initially, animals showed no tendency to imitate or not to imitate each other. When one group was rewarded for following a leader and another was rewarded for going in the opposite direction in a T maze, definite learning of the expected kind took place. After this type of imitative behavior had been learned, it was found to generalize to other leaders, different drives, and even situations calling for different behavior. Comparable results have been obtained in experiments with children. IDENTIFICATION. There is a marked tendency on the part of both children and adults to pattern their behavior after the supposed behavior of some "ideal" person. For younger children, the parents are often the models. For older children heroes and heroines become important. It can be seen readily that the process of identification is a special case of imitation. Early identification occurs with parents because parents usually have sufficient ego-strength to feel that their own behavior patterns are worth copying. They therefore tend to reward imitation and punish failure to imitate. In this way, family behavior patterns are easily passed on from one generation to the next, particularly in stable cultures. Thus, it is that the autocratic father produces autocratic sons, and the hypochondriacal mother is imitated by her daughters. Of course, there are many other factors affecting this kind of behavior transmission. Its cultural advantages and disadvantages must be obvious. A folk hero is set up and is endowed with the kind of behavior which is approved in the particular society. Then individuals identify with the hero and try to imitate his behavior. This makes for cultural uniformity and also often for a deadening stereotypy. CONFORMITY. Most groups reward members who are like other members in their behavior and punish members who deviate. Thus, the need to conform acquires a considerable strength. You attend church because of what neighbors might say, keep your lawn cut, shave, wear clean clothes, avoid profanity, etc., because of this need to conform. Studies have shown that leaders are usually persons who conform and deviates become scapegoats very easily. Conformity in a group makes for more efficient and pleasant group action but carries with it the danger of destroying creativity and new ideas. Conformity is closely related to imitation and identification.

SEX. There are many types of secondary drive associated with sex. In some cultures, women are treated as property; the prettier and more numerous the wives, the greater the status of the husbandWhere great value is placed on masculinity and femininity, sex behav-

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ior becomes the vehicle for "proving" oneself. In the case of the female, security can be bought by appropriate bedroom behavior. In a society where sex is "bad," all sorts of taboos and prohibitions gain drive value. Although satisfaction of the primary sex drive could be and is in some groups as little a problem as satisfying hunger for food, in most groups it is associated with fears and anxieties. These may be so strong that normal satisfaction becomes impossible, particularly in the case of females. Frigidity and impotence result, and the thwarted sex drive seeks expression through other channels. Sublimation, or detour behavior for sex satisfaction, has been responsible for many great cultural accomplishments. Secondary drives associated with sex are very important. The number and the complexity of their interrelationships precludes anything more than a rather superficial discussion at this point. COMPLETION OF A TASK. It has been observed that a person who has started a task often takes it up again after an interruption. Although some psychologists have taken the position that there is a primary drive for task completion, there is considerably more basis for treating it as a secondary drive. Zeigarnik (34) made one of the early systematic studies. Subjects were presented with a number of tasks during one sitting, half of which they were allowed to complete and half of which were interrupted after they were well along toward solution. At the end of the session subjects were asked to tell what they had been doing during the hour. Incomplete tasks were remembered about twice as well as were completed ones. Many variables affect the outcome of this kind of experiment. There is less tendency to resume a task when it is ego-threatening, when it is not interesting, and when it is not possible to tell for sure whether one has finished or not. Many other secondary drives have been named, in fact, so many that even listing the names would take up pages. There are drives for group membership (gregariousness), dominance, submission, child care in humans, respect for authority, approval, avoidance of rejection, learning, leadership, social recognition, etc. Any reasonably complete discussion of secondary drives would touch on most of human social behavior and would thoroughly cover the field of psychodynamics.

Methods of Studying Secondary Drives.—To some degree, each of the methods mentioned for studying primary drives could be used to study secondary drives. Certain of the methods have shown themselves actually useful: modifications of the obstruction box, introspective reports, work output, activity records, and projective tests. Additional methods have proved valuable in the study of secondary

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drives. One can actually set up secondary drives experimentally and determine the effects of numerous variables on the process. Of particular value are such techniques as association, study of personal documents, and the giving of questionnaires and inventories. ASSOCIATION. Association has been used extensively by the "analytic" schools in the study of personality structure as well as in therapy. Two basic methods have been developed: the word association technique of Jung and Luria, and the free association technique of Freud. In word association, the patient is requested to respond as quickly as possible with the first word that comes into his mind after the tester has called out a stimulus word. Responses are studied for delays and peculiarities, which are supposedly indicative of disturbances. Lists of responses to standard words have been made up, so that it is possible to determine how much a given patient's responses are like those of known normals. The association can be controlled or limited by instructions, as, for example, to give only adjectives or only opposites. The free association method used by psychoanalysts is somewhat different. The patient simply relaxes and says anything that comes to mind. To a considerable degree, his own thoughts and feelings serve as stimuli to further association. The material thus produced can be analyzed as to content, and the manner in which it is produced gives further clues to associated feelings. Here again blocks ( "resistances" ) are taken to indicate disturbances. Association can start with almost any stimulus, including what is remembered of dreams. STUDY OF PERSONAL DOCUMENTS. AS long as people have been interested in each other, they have observed each other's behavior. Students of literature search the writings of authors for clues as to their interests and drives. Writing cannot be done in a vacuum, and the actual context is the experiences of the author. Thus, novels can be interpreted pretty much in the same way as projective tests. Allport (2) made an extensive historical survey of the types and uses of personal documents and concluded that they can be utilized scientifically. To appreciate the significance of such material, you need only to observe what happens when you find an old diary belonging to your mother, sister, husband, or wife and are caught reading it. QUESTIONNAIRES AND INVENTORIES. We can ask an individual a standardized list of questions to determine the strength of a drive and its modes of expression. Kinsey has very successfully used this method in his studies of sex behavior, asking hundreds of questions.

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Vocational guidance is often based upon answers to questions in a paper-and-pencil test. The client's answers are compared with those of persons with known motivations and interests and the inference is made that his motives are similar to those of persons who have answered as he did. Public opinion polls estimate drive to behave a certain way in an election or when buying a certain type of product on the basis of answers to questions. In all these cases, the rather shaky assumption is made that verbal behavior is an adequate indicator of drives. Unfortunately, this assumption is not always confirmed in practice. Numerous studies have shown that it is possible to fake answers to questionnaires and inventories and thus to create false impressions about one's motives. The tester must always be careful to estimate the probable effect of attitudes on answers. Special Problems with Drives Some areas of behavior involving drives have been of particular importance and have become centers of attention and often of controversy. Perhaps the best way to illustrate the complexity of drive problems is to tell something about several of these areas. The relationship between drives and language, conflict and neurosis, and the hierarchy of motives all seem to be of sufficient practical and theoretical significance to warrant discussion. Drives and Language.—There are almost limitless possibilities for the control of drives by language. To begin with, repression of sensations is taught by language. The woman who claims to have no sex feelings at all has very probably been brought to this by various forms of symbolic behavior on the part of those around her in childhood. Hypnosis, by the manipulation of language, can often produce and eliminate at least consciousness of secondary and even primary drives. The original use of hypnosis by the medical profession was to minimize or eliminate pain and anxiety associated with surgery. Complete anesthesia for pain can be produced hypnotically in many persons and is being induced in childbirth. On the other hand, it is also possible to produce sensations of pain, thirst, and hunger by verbal suggestion. A very impressive demonstration of this process is based on the suggestion under hypnosis that a piece of chalk is a lighted cigarette. When touched on the hand with the "burning end," the subject cries out and withdraws his hand. A "good" subject will often develop a blister at the touched spot. Medical men have to face this kind of

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problem regularly in the form of symptoms suggested to patients by "friends" or other doctors. Social motivation is almost completely dependent upon language. Without a common language, there could be very little communication, and so there would be little induction of socially oriented drives. Psychotherapy is pretty much based upon communication of drives and motives. It has even been proposed that successful therapy consists of attaching names to feelings so that the individual is now conscious of these feelings and is able to deal with them directly. Conflict and Neurosis.—Many theories have been proposed to account for neurotic behavior, and all of them utilize the concept of drive in some way or other. A simple, of a necessity even oversimplified, theory follows : The child learns to recognize a sex drive, and to satisfy it by masturbation. His parents observe the masturbation and punish him physically and by threat of withdrawal of love. This produces a feeling of anxiety which becomes attached to the sex drive. The stronger the sex drive, the greater the anxiety. The child now discovers one day that by striking himself with a stick he gets a feeling of relief. We now have an irrelevant behavior pattern set up, and can say we have a neurosis, based upon a conflict of drives. Masserman (20) reports work with cats along this line. The cats first learned to obtain food from a food box, then were subjected to a shock or air blast when they attempted to open the box. Here was a conflict between hunger and anxiety. One of the symptoms developed was a refusal to eat accompanied by passive catatonic-like behavior. This behavior was nonadaptive, but it persisted over long periods of time, even to the point of death from starvation. Further study of conflict and neurosis must of course include study of the place of drives in their development and maintenance. Hierarchy of Motives.—When several motives are present at the same time, we can usually observe one or another taking precedence. Maslow (19) has proposed that there are at least five sets of goals or basic needs: physiological, safety, love, esteem, and self-actualization. These are arranged in a hierarchy of prepotency such that the most prepotent goal monopolizes consciousness and the efforts of the individual. When one need is fairly well satisfied, the next most prepotent need in the hierarchy emerges to dominate the conscious life. Kilby (13) points out that this theory accounts for certain behavior in stress situations. In Germany immediately after the recent World War, people were busy trying to satisfy physiological needs and there was a drop in "psychoneurosis." Where people are starving, their

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primary concern is to obtain food. Finally, there was a definite decrease in the incidence of neurosis among civilians in England during the time of the great air raids. Summary Drives or motives have some sort of physiological basis, vary in strength, release energy, lead to learning, and are affected by learning. They can perhaps best be considered as imbalances in the organismenvironment field and can be divided roughly into primary or unlearned drives and secondary or learned drives. Hunger and thirst are good examples of primary drives, while imitation and conformity are secondary drives. Many methods have been developed to study both primary and secondary drives, such as those using the obstruction box and projective techniques. Special problems arise with respect to the effect of language on drives, conflict and neurosis, and the relative strength or prepotency of various drives. REFERENCES 1. ADOLPH, E. F. The internal environment and behavior: III. Water content. Amer. J. Psychiat., 1941, 97, 1365-73. 2. ALLPORT, G. W. The use of personal documents in psychological science. Soc. Set. Res. Coun. Bull., 1942, No. 49. 3. BASH, K. W. An investigation into a possible organic basis for the hunger drive. /. comp. Psychol., 1939, 28, 109-35. 4. BELLOWS, R. T. Time factors in water drinking in dogs. Amer. J. PhysioL, 1939, 125, 87-97. 5. CANNON, W. B. The wisdom of the body. New York: W. W. Norton & Co., Inc., 1932. 6. . Hunger and thirst. In MURCHISON, C, A Handbook of general experimental psychology. Worcester, Mass.: Clark University Press, 1934. 7. CANNON, W. B., and WASHBURN, A. L. An explanation of hunger. Amer. J. PhysioL, 1912, 29, 441-54. 8. COWLES, J. T. Food tokens as incentives for learning by chimpanzees. Comp. Psychol. Monogr., 1937, 14, No. 5. 9. EWARD, J. M. Is the appetite of swine a reliable indication of physiological needs ? Proc. Iowa Acad. Set., 1916, 22, 375-414. 10. HALVERSON, H. M. Genital and sphincter behavior of the male infant. / . genet. Psychol., 1940, 56, 95-136. 11. HULL, C. L. Stimulus intensity dynamism (v) and stimulus generalization. Psychol. Rev., 1949, 56, 67-76. 12. JOHNSON, H. M., SWAN, T. H., and WEIGAND, G. E. In what positions do

healthy people sleep? / . Amer. med. Ass., 1930, 94, 2058-62. 13. KILBY, R. W. Psychoneurosis in times of trouble: evidence for a hierarchy of motives. / . abnortn. soc. Psychol., 1948, 43, 544-45. 14. KIMBLE, G. A. Evidence for the role of motivation in determining the amount of reminiscence in pursuit rotor learning. / . exp. Psychol., 1950, 40, 248-53. 15. KINDER, E. F. A study of the nest-building activity of the albino rat. / . exp. Z00L, 1927, 47, 117-61.

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16. KINSEY, A. C, POMEROY, W. B., and MARTIN, C. E. Sexual behavior in the

human male. Philadelphia: W. B. Saunders Co., 1948. 17. KLEITMAN, N. Sleep and wakefulness as alternating phases in the cycle of existence. Chicago: University of Chicago Press, 1939. 18. MCCLELLAND, D. C, and ATKINSON, J. W. The projective expression of needs. 1. The effect of different intensities of the hunger drive on perception. / . Psychol, 1948, 25, 205-22. 19. MASLOW, A. H. A theory of human motivation. Psychol. Rev., 1943, 50, 370-96. 20. MASSERMAN, J. H. Behavior and neurosis: an experimental psychoanalytic approach to psychobiologic principles. Chicago: University of Chicago Press, 1943. 21. MILLER, N. E., and DOLLARD, J. Social learning and imitation. New Haven: Yale University Press, 1941. 22. PERIN, C. T. Behavior potentiality as a joint function of the amount of training and the degree of hunger at the time of extinction. / . exp. Psychol., 1942, 30, 93-113. 23. RICHTER, C. P. Animal behavior and internal drives. Quart. Rev. Biol., 1927, 2, 307-43. 24. RICHTER, C. P., HOLT, L. E., and BARELARE, B. Nutritional requirements for

25. 26. 27. 28. 29. 30. 31. 32. 33. 34.

normal growth and reproduction in rats studied by the self-selection method. Amer. J. Physiol., 1938, 122, 734-44. ROBINSON, E. A., and ADOLPH, E. F. Pattern of normal water drinking in dogs. Amer. J. Physiol, 1943, 139, 39-44. SKINNER, B. F. The behavior of organisms: an experimental analysis. New York: Appleton-Century-Crofts, Inc., 1938. TAUBER, E. S. Effects of castration upon the sexuality of the adult male. Psychosom. Med., 1940, 2, 74-87. TSAI, C. The relative strength of sex and hunger motives in the albino rat. 7. comp. Psychol, 1925, 5, 407-15. TSANG, Y. C. Hunger motivation in gastrectomized rats. / . comp. Psychol, 1938, 26, 1-17. WANG, G. H. Relation between "spontaneous" activity and oestrus cycle in the white rat. Comp. Psychol. Monogr., 1923, 2, No. 6. WARDEN, C. J. Animal motivation studies. New York: Columbia University Press, 1931. . The relative strength of the primary drives in the white rat. / . genet. Psychol, 1932, 41, 16-35. YERKES, R. M. Sexual behavior in the chimpanzee. Hum. Biol, 1939, 11, 78111. ZEIGARNIK, B. tlber das Behalten von erledigten und unerledigten Handlungen. Psychol. Forsch., 1927, 9, 1-85.

Chapter 6 DETERMINANTS AND COMPONENTS OF PERSONALITY By CLYDE KLUCKHOHN, Ph.D., and

O. HOBART MOWRER,

Ph.D.

"CULTURE and personality" is one of the fashionable slogans of contemporary social science and, by present usage, denotes a range of problems which are on the frontier of anthropology and psychology. However, the phrase has unfortunate implications. As Lynd (37, p. S3) has pointed out, a dualism is implied, whereas "culture in personality" or "personality in culture" seems to suggest conceptual models more in accord with our data. Moreover, the slogan favors a dangerous simplification of the problems of personality. A "lust after absolutes," according to John Dewey, is a striking feature of American character structure, and this trend is far from absent in our science. Recognition of culture as one of the determinants of personality is a great gain, but there are indications that this theoretical advance is tending in some professional circles to obscure the significance of the other determinants. Actually, the primary purpose of this chapter is to show that any consideration of "personality in culture" must be carried on within the framework of a complex conceptual scheme which explicitly recognizes a number of classes of determinants. Just as some investigators have neglected certain determinants, so have other investigators remained unaware of the manifold nature of personality and have confused one or two components with the whole personality. We follow May (40) in assuming that the parameters of a personality may be defined by a human organism's effects upon others.1 All 1 We are not unaware of the difficulties into which a rigorous adherence to this definition leads. We see, for example, the implications of Frank's (11) point: "The conception of the individual 'life space' or 'private world' implies the view that the stimulus-situation, however objectively denned and standardized, will mean to each subject what he projects therein." Our awareness of other problems is indicated in another publication (44). Indeed the position adopted there is appreciably different from that taken here. We feel that this course is justifiable on two grounds. First, in the present confusion in the very difficult terrain of personality theory, we think there is some utility in developing the logical consequences of a widely accepted definition of personality. Second, we are addressing ourselves to two different sets of Questions in our two publications. In this chapter the interest centers upon classifica105

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attempts to describe an individual "as he really is" must be regarded as extrascientific unless they are firmly based upon the regularities in the stimulus value which this individual has for others. The only way an observer can "know" other personalities is by noting and making inferences from their social stimulus value—whether in casual social relationships, in controlled interviews, or as manifested in more refined experimental situations such as those provided by the various projective techniques. A subject's own statement of his needs, motives, etc. will normally constitute an important part of the data but can never be taken at its face value without critical evaluation—it must always be interpreted in terms of the reactions of one or more observers. The definition of personality as social stimulus value seems to us one which will permit relatively objective operations. All scientific theories must take account both of similarities and of differences. A theory of personality must explain equally the ultimate uniqueness of each personality and the observed fact of personality types. More specifically, a conceptual scheme must be adequate to accommodate five generalizations: 1. All human beings have certain properties of social stimulus value or personality traits in common. We shall call these universal traits or components, and their antecedents universal determinants. 2. The members of any given society tend to share more personality traits with each other than with the members of other societies. We shall call such traits communal traits or components, and their antecedents communal determinants. 3. Within a society the behavior characteristic of certain groups or categories of persons shows some constancies. The social stimulus value of those who are playing the same role has a common quality. We shall call this the role component, and the antecedents of traits dependent upon roles the role determinants. 4. The members of any given society, even those who are playing similar roles, differ among themselves in social stimulus value. We shall call such distinctive and relatively unique traits idiosyncratic traits or components, and their antecedents idiosyncratic determinants. tory abstractions and upon the query: how do we attain our knowledge of personality? The other paper has a point of view which might be designated as "clinical"; the central question is more nearly: what is personality? Here personality is seen largely from the standpoint of the reactor; there we try to see personality as it may be imputed to the actor. Perhaps a philosopher might say that the point of view of this chapter approaches the "epistemological," that of the other, the "ontological." The history of science permits two inductions: (a) it is useful to behave experimentally with respect to conceptual schemes without necessarily claiming "truth" for one to the exclusion of another; (6) a conceptual scheme may be appropriate for analyzing one group of problems, but utterly inappropriate for treating the same data in the light of a different group of equally legitimate questions.

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5. Certain similarities, other than those common to all humanity, may be observed in the social stimulus value of individuals from different societies—even where the personality manifestations for those societies vary widely. The possibility of such similarities is, however, deducible from the fact that idiosyncratic determinants are not societybounded. Consequently, we need no special designation for nor explanation of such similarities. Our conceptual scheme thus embraces two classes of concepts and their interrelations. On the one hand, there are the determinants: those classes of forces which may be abstracted out as influencing social stimulus value. On the other hand, there are the components of personality: those facets of the social stimulus value of the individual as an integrate in action which may be regarded as produced primarily by one or another of the classes of determinants.

The Determinants of Personality First, we must note that this pie, like all others, can be sliced in more than one way. In speaking of the forces operative in personality formation it has been customary to deal with such abstractions as "the biological," "the cultural," "the environmental," and the like. Such abstractive isolates are useful, but, if the primary purpose is to show how total stimulus value may be segregated into various facets or components, these are second-order abstractions. That is, such determining forces as "the biological" and "the cultural" are only elements in abstractions such as "universal" and "communal" which may be linked more immediately to the components of personality. No single component can be regarded as the product of forces which are exclusively biological or cultural. But "the communal component" may be directly connected with the partly biological, partly social, partly cultural, partly physical environmental influences which act upon all members of a single society and which hence may be subsumed as the "communal determinants." Let us now examine systematically and in detail the interdigitation of personality determinants classified as "universal, communal, role, and idiosyncratic" with personality determinants classified in a more familiar manner. We have heard Clark Hull say, "In the beginning there is (a) the organism and (6) the environment." Using this dichotomy as a starting point in analyzing the determinants of personality, one might say that the differences observed in the personalities of human beings are due to variations in their biological equipment and in the total environment to which they must adjust, while the similarities are to be under-

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stood as resulting from biological and environmental uniformities. But such an overly general and overly simple formulation—although useful as a first approximation—will not, unless it be further developed, lead us to hypotheses which have predictive value. We realize, of course, that even the dichotomy which Hull proposes is an abstraction, for, as Henderson (21) has pointed out, the organism and the environment have a kind of wholeness in the concrete behavioral world which the student loses sight of at his peril. While acknowledging the abstractive nature of the process, it is nevertheless necessary for us to distinguish three aspects of the environment—the physical, the social, and the cultural. Table 1 shows in a schematic way how the two classificatory systems cut across each other in a symmetrical manner. TABLE 1 COMPONENTS OF PERSONALITY*

Determinants Biological

Universal Birth, death, hunger, thirst, elimination, etc.

PhysicalGravity, temenvironmental .. perature, time, etc.

Communal

Role

Idiosyncratic

"Racial" traits, Age and sex difnutrition level, en- ferences, caste, demic diseases, etc. etc.

Peculiarities of stature, physiognomy, glandular makeup, etc.

Climate, topogDifferential raphy, natural re- access to matesources, etc. rial goods, etc.

Unique events and "accidents" such as being hit by lightning, etc.

Social

Infant care, group life, etc.

Size, density, and Cliques, "marSocial "accidents" distribution of ginal" men, etc. such as death of population, etc. a parent, being adopted, meeting particular people, etc.

Cultural

Symbolism, tabu on incest and ingroup murder, etc.

Traditions, rules of conduct and manners, skills, knowledge, etc.

Culturally dif- Folklore about acferentiated roles cidents and "fate," etc.

* For helpful suggestions as to terminology we are indebted to Drs. Leland H. Jenks, Ralph Linton, and John Whiting. For general discussions which have materially assisted in the clarification of this conceptual scheme we are indebted to Dr. Florence Kluckhohn.

Although the sixteen cells formed by this two-way system of classification are logically exhaustive, the items which are entered in these cells are, of course, merely illustrative. The following discussion will expand the significance of each cell, indicate the dynamic interrelated-

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ness of the determinants, give some perspective on present knowledge of each, and further develop the logic of the conceptual scheme as a whole. Universal, Communal, Role, and Idiosyncratic Determinants.— The universal determinants of personality arise out of four facts: (a) man is an animal of distinctive physical appearance and with somewhat distinctive biological equipment; (b) man is a social animal; (c) man is a cultural animal, and (d) man lives in a physical world which obeys certain natural laws. All human beings normally have two hands and two feet at birth (not four feet and only most exceptionally one hand or three hands). Such properties as stereoscopic vision, which differentiate the human species from most other living organisms, immediately imply common features of personality. As animals, all men are also bound to face certain problems: they are born : they must breathe, eat, and excrete; they have imperious sexual and other needs; they grow; they face death. As social animals, they must adjust to dependence upon their society and groups within it. As cultural animals, they must adjust to culturally defined expectations. Finally, all men must adapt themselves to an external physical world. That these facts do constitute problems for human beings is attested by common experience; yet the import and meaning of these facts have not been fully analyzed from the point of view of personality theory, nor do they seem likely to be in the near future for the reason that, being universal determinants, their meaning cannot be demonstrated by the usual methods of contrast and comparison. These are background phenomena, the invariables and inevitables to which man must bow and somehow adjust. That "human nature" would be strikingly different from what it is if the human animal had not assumed upright posture and developed prehensile hands, stereoscopic vision, and a nervous system which makes elaborate speech possible goes without saying; and here we have a clearer perception of the significance of this distinctively human cluster of biological traits since we can see what their absence implies in other animals. Contemporary "superman" fantasies give us perhaps our only glimpse of what human beings would be like if they lived in a world without gravity, temperature, or time. Since the universal determinants are relatively constant for all mankind, they provide no explanation either of personality typologies or peculiarities. If, however, we notice how certain universal or almost universal experiences (cf. 45, p. 287) derive a special phrasing

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from the interaction of the biological determinants with the realities of the social, cultural, and physical environment, we shall begin our systematic understanding of the observed variation in the social stimulus value of individuals. All men are born helpless; the external impersonal world presents threats to survival; the human species would disappear completely if social life were abandoned. But the human adaptation to the external world depends not merely upon that mutual support which is social life; it also depends upon culture. Many types of insects live socially yet have no culture. They depend for survival upon behavioral dispositions which are transmitted within the germ plasm. Other organisms show great capacities to learn from experience. Human beings, however, learn not only from experience but also from each other (cf. 34, esp. chaps, v and vi). All human societies rely greatly for their survival upon accumulated learning (culture). All human culture is a storehouse of ready-made solutions to problems which human animals face (10). Into this storehouse are garnered not merely the pooled learning of the men who interact in any one society at any given point in time but also much of the learning of many men long dead, of many men from other societies. This capacity of human beings not only to learn but likewise to teach each other is not the least important of the universal determinants. For example, culture as well as the other three classes of determinants brings it about that throughout the life sequence all men experience both gratifications and deprivations. All persons receive some deprivations and frustrations from the impersonal environment (weather, physical obstacles, and the like interfere with the wishes of men) and from biological conditions (bodily incapacities, illnesses, etc.). Likewise, social life (whether in the anthill, the beaver colony, the herd, or the human group) means some sacrifice of autonomy, some subordination and superordination. But the pleasure and pain men receive from one another depend not simply on physical facts, biological limitations, and the sheer conditions of social interaction: they depend too upon what the accumulated learning has taught them to expect from one another. All human personalities are formed under this common condition of demands for conformity to cultural expectation. But the specific character of the cultural expectations varies greatly among different societies and even among different groups in the same society. This brings us from the universal to the communal and role determinants. All human beings not only have to be socialized—they are always socialized as members of particular societies and often as members of differentiated categories within the society.

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Membership in a society carries with it exposure to determinants of social stimulus value approximately constant for all members of that society. How large or how small a grouping one takes as "a society" is primarily a matter of convenience for the problem in hand. By and large, the physical traits and the total environment of Western Europeans do present a contrast to those of Mohammedans or Eastern Asiatics. White citizens of the United States, in spite of regional, ethnic, and class differences, can usually be distinguished, on the basis of their social stimulus value, from Englishmen, Australians, or New Zealanders. From the point of view of personality formation, there is a hierarchy of "societies" to which any individual belongs, ranging from very large units down to the local community.2 How inclusive a unit one considers in speaking of communal determinants is purely a function of the level of abstraction at which one is operating at a given time. Some of the personality traits which the members of the same society have in common but which distinguish them from humanity as a whole unquestionably derive from distinctive biological heredity. Such persons look alike both to each other and to representatives of other societies. This similarity stems in part from uniformity of clothing and other personal artifacts, but the fact that persons who live together are more likely to be related biologically than are persons who live far apart means that "race" is a biological determinant of personality at the communal level of analysis. Biological factors common to a given society may, of course, manifest themselves, not only in terms of appearance, but also, less directly, in behavior. If the metabolic rate is typically low for one group as contrasted with other groups or if certain types of endocrine imbalance are unusually frequent, the social stimulus value of the members of that society will certainly have distinctive qualities. We have as yet, however, very little unequivocal information on this class of determinants (cf. 28, chap, vi), but their importance in some cases seems unmistakable. Likewise, we know almost nothing of what are the effects upon personality of communal constants in the impersonal environment. Does living in continually rainy weather create a social stimulus value different from that of living in a sunny, arid country ? What are the differential effects of living in a walled-in mountain valley, on a flat plain, or upon a high plateau studded with wind-sculptured red buttes ? 2 Cf. Homans (22, p. 403) : "If we return from the word society to the facts we had in mind when we used it, we find that these human beings are acting, behaving, that they are acting in response to the actions of one another, and that the interactions are more frequent between fellow-members of the society than they are between the 'members' and other men whom we choose to consider outsiders."

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Thus far we can only speculate, for we lack controlled data. The effects of climate (cf. 43) and even of topography may be considerable, although they have hardly been rigorously explored. There are certain social, as opposed to cultural, determinants for each society. Thus the size of the society and the density of the population are certainly not prescribed or even determined indirectly by the culture, although they are often conditioned by the interaction between the technological level of the culture and the exigencies of the physical environment. The location of a population—as well as its size and density—is a determining factor. Thus the type of social interaction (with its consequences for personality formation) will be different if a village of 1,000 persons occupying an area of one square mile is located in central Kansas or within thirty miles of New York City. The cultural facet of any society is a signally important determinant of both the content and the structure of the personalities of members in that society. The culture very largely determines what is learned, for instance, available skills, standards of value, and basic orientations to universal problems such as death. Culture likewise structures the conditions under which learning takes place: whether it is from parents or parent surrogates, from siblings, or from those in the learner's own age grade, whether it is gradually and gently acquired or suddenly demanded, whether renunciations are harshly enforced or reassuringly rewarded. To say that "culture determines" is, of course, a highly abstract way of speaking. In the behavioral world what we actually see are parents and other older and more experienced persons teaching younger and less experienced persons. We assume that biology sets the basic processes which determine how man learns, but culture, as the transmitted experiences of preceding generations (both technological and moral) very largely determines what man learns (as a member of a society rather than as an individual who has his own private experiences). Culture even determines to a considerable extent how the teaching that is essential to this learning shall be carried out. Logically, the role determinants could have been encompassed within the communal, for the reference is again to those determinants of personality which operate upon particular groups. But the fact that every society embraces units of social differentiation is so basic and its consequences for personality formation are so tremendous (and so often neglected) that the distinction seems necessary or, at the least, highly useful. In the personality context, the important criterion is always: to what social categories do the individual and those socializing him have a sense of "belongingness" (or of aspiration) ? Certain

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categories are fundamentally biological. In every society the organism is differentially socialized according to sex. In every society different behavior is expected of individuals in different age groups,3 although where these lines are drawn and what behavioral variations are anticipated differ in different cultures. In all known caste societies physical criteria are to some extent involved, and class differentiations are often also tinged with appearance differences. The correlation of the role and physical environmental determinants rests upon the fact that some categories of persons within a society generally have differential access to residential locations, house types, and material goods. As for the role-social determinants, there are always some social groupings (cliques, for example) which are neither rationalized along biological lines nor prescribed by the ideal patterns of the culture, but are of enough permanence to be important for personality formation. Finally, culture regulates the type of behavior deemed appropriate to individuals of a particular age, sex, and status. That endless idiosyncratic variations can and do occur in the life of each human being hardly requires extensive documentation. A child is born a cripple. He is nearly drowned by a sudden flood in a canyon. If the death of a parent means that an infant goes to live with an aged grandmother, or if the remaining parent takes a new mate with a psychopathic personality, the outcome for the child must necessarily be different than if the original parent had survived. Even casual social contacts of brief duration ("accidental"—not foreordained by the cultural pattern of social interrelations) often seem crucial in determining whether one's life proceeds along one or another of various possible courses. While some cultures do prescribe different treatment for the oldest or youngest child in a series, the fact that a particular child occupies such a distinctive position is an "accident" from the point of view of the cultural system. Biological, Physical-Environmental, Social, and Cultural Determinants.—We have now sketched the manner in which universal, communal, role, and idiosyncratic determinants of personality all include biological, physical-environmental, social, and cultural elements. Let us now reverse the emphasis, taking the classes of determinants along the horizontal axis of Table 1 as our point of departure. There is a vast literature, much of it still highly controversial, on the extent to which biological (organic, constitutional) determinants niold the personality. Here we can scarcely do more than indicate that we recognize the significance of this factor (cf. 53). At the same 3

On the significance of age and sex groups, cf. Linton (35, 36).

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time we must also point out the ambiguities of such an interpretation. As Woodworth (53, p. 84) observes, "there are serious difficulties in the way of separating the factors of heredity and environment when our interest lies in such traits as human intelligence and personality." Because the individual's body is the one factor which seems to be constant in various situations, some students have succumbed to the temptation of assuming that the biologically inherited idiosyncratic properties of the organism are the chief, if not the sole, determinants of such individual behavioral consistencies. For example, when Jost (26) reports that the physiological changes produced by frustration vary in different children, it is tempting to jump to the conclusion that these differences represent constitutional differences in frustration tolerance. This may well be an important part of the explanation, but we must not overlook the fact that the children who were studied must necessarily also have had different learning experiences. Sheldon (50) submits data purporting to show a high degree of correlation between somatotype and temperament. Newman (46, p. 172), on the other hand, says that "motor activity and temperament seem to be least influenced by heredity." Rich (47) obtained correlation coefficients of only .20 to .30 between metabolism and selected personality traits. Such negative results may, of course, reflect merely the inadequacy of present concepts and research techniques, but the divergent views of contemporary investigators in this field certainly provide little basis for unequivocal conclusions at present. Although there is little doubt that different genetic structures have different potentialities, the complicated interrelations of heredity and environment, which are probably most effectively studied by the methods of co-twin control (see 16), are as yet but little understood. That an interrelation is almost always involved seems to be the best premise for the moment. Therefore, the conclusion of Lynn and Lynn (38), based on an examination of a large number of subjects, that there is a single organic determinant (face-hand laterality) of "two definite and opposite personality types," must be regarded with reserve, pending independent confirmations. The old "problem" of "heredity or environment" is, then, we feel, essentially meaningless. The only pertinent question is: Which of various genetic potentialities will be actualized as a consequence of a particular series of life events in a given physical, social, and cultural environment ? The particular socialization process institutionalized by a given culture and the accidents peculiar to a given life history may be more or less favorable to the acquisition of certain skills or the development of certain behavior trends, but biology undoubtedly imposes

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some limitations. There are substantial reasons for believing that learning ability varies greatly on hereditary grounds (52, pp. 391-99). The various inherited malfunctions are too obvious to require comment. Genetic factors also shape personality through such physical traits as nature, pigmentation, strength, beauty of form, regularity of features, etc. The kind of world one finds about oneself is to a considerable extent determined by the way other people react to one's appearance and physical capacities. Thus, a hunchback does not expect to become a matinee idol, nor a spindle-legged boy a great athlete. Occasionally a physically weak youth, such as Theodore Roosevelt was, may be driven to achieve feats of physical prowess as an overcompensation, but usually the individual accepts exclusion from some types of vocational and social adjustments on the basis of his physical make-up, even though concealed resentments may remain as important ingredients in his total personality. Conversely, special physical fitnesses make certain other types of adjustment particularly congenial (5). Although biology is one of the idiosyncratic determinants of personality, there are only a few extreme cases in which an individual is committed in detail by his particular genetic equipment to particular psychological traits. Even when there is a definite physical handicap, such as deafness (4, 17), the variations are wide. Nevertheless one must always be alive to the possibility of constitutional determinants. Levy (33) has recently presented evidence for the existence of constitutional factors in maternal behavior. And, as Schilder (49) says, "A constitutional factor would explain why experiences of similar type are in the one case traumatic (producing a point of fixation) and not traumatic in another case." Freeman (12, pp. 562-70) says, ".. . one important physiological basis of temperamental differences [is] connected with the reactivity of nervous systems. Various degrees of hyperactivity and hypoactivity of individuals as well as other differences in personality are thought to stem from this fundamental neural difference." This conclusion seems confirmed by the finding of Fries (13, p. 167) that during the first ten days of life infants vary reliably with respect to amount of activity during both sleep and waking hours, amount of sleep required, sensitivity thresholds, and patterns of response to thwarting. These differences were found to remain "fairly constant" into the third year of life (14, p. 730). Mendelian genetics have taught us that the particular heredity which a new organism gets from the two genetic lines which are crossing depends upon the accidental way in which the two germ cells exchange chromosomes at the time of fertilization. Except for siblings produced from a single fertilized egg, children having the same parents

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will have a somewhat different heredity. The idiosyncratic biological determinants which we have been discussing thus take their origin in these "accidents" of the genetic processes. Other idiosyncratic biological determinants exert their force as a result of some adventitious circumstance during uterine development. Some factors that we are likely to pigeonhole all too complacently as "biological" often turn out, on careful examination, to be the products of complicated interactions. A crippling illness, for example, may well be partly the consequence of a constitutional predisposition but also partly the consequence of the individual's participation in a caste or class group where sanitation and medical care are inadequate. A tendency toward corpulence has personality implications both when it is characteristic for a group and when it distinguishes an individual within a group (cf. 3). But the resources of the physical environment as exploited by the culturally available technology generally are the major determinants of vitamins, noxious substances, and nutrition, and it is these which have patent consequences for corpulence, stature, and energy potential. If hookworm is endemic in a population, one will hardly expect vigor to be a striking feature of personality (cf. 18, p. 54). Yet hookworm is not an ineluctable "given," either environmentally or biologically: the effects and prevalence of hookworm are dependent upon culturally enjoined sanitation facilities and other culturally available types of control. The same complicated type of interrelation may be noted between the physical and cultural environments. On the one hand, the physical environment may impose certain limitations upon the cultural forms which man creates, or it may limit change and readjustment in the culture which he brings into an ecological area. There is always a portion of the external environment which man can and does adjust to but which he can only very partially control. On the other hand, even a part of the impersonal environment is man-made and cultural. A culture may provide technologies which permit some alterations in the physical world (for example, by constructing irrigation ditches or by terracing hillsides). There are also those artifacts (houses, furniture, tools, vehicles) which add to the resources for gratification (and frustration). Most important of all, culture screens man's whole perception of the physical world. Sherif (51) has shown experimentally the effects of social suggestion in setting frames of reference for perception. Hallowell (19, pp. 20-21) has excellently indicated how culture acts as a set of blinders, or lenses with certain distortions, through which acculturated human beings view the whole world (including other human beings and themselves). Hallowell says:

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Man's psychological responses to the physical objects of his external environment can only be understood . . . in terms of the traditional meanings which these latter have for him. He never views the outer world freshly or responds to his fellows entirely free from the influences which these meanings exert upon his thought and conduct. Celestial and meteorological phenomena, for example, or the plants and animals of man's habitat, even its inanimate forms, are never separated as such from the concepts of their essential nature and the beliefs about them that appear in the ideological tradition of a particular cultural heritage. Man's attitude toward them is a function of reality as culturally denned, not in terms of their mere physical existence. Thus, to treat the physical environment in which a people lives independently of the meaning that its multiform objects have for that people involves a fundamental psychological distortion if we aim to comprehend the universe which is actually theirs. While useful in certain kinds of analysis, even the assertion that two peoples occupy the same natural environment because the regions inhabited by them exhibit the same climatic type, the same topography and biota can only have significance in the grossest physical sense. It is tantamount to ignoring the very data which have the most important psychological significance, namely the differences in meaning which similar objects of the phenomenal world have for peoples of different cultural traditions. Consequently, the objects of the external world, as meaningfully defined in a traditional ideology, constitute the reality to which the individuals habituated to a particular system of beliefs actually respond. As applied to the sphere of ecological relations, for example, an inventory of all the natural resources of a specific human habitat does not necessarily correspond to the "natural resources" of that habitat. The physical objects of the environment only enter the reality-order of the .human population as a function of specific culture patterns. It is the knowledge and technological level of the culture of a people that determine their natural resources, not the mere presence of physical objects. To people without a tradition of pottery-making the presence of clay in their habitat is no more a natural resource than was the presence of coal and iron in the habitat of the pre-Columbian Indians of eastern North America. These words, written by an anthropologist, are readily translatable into psychological terms. They say, in effect, that the perceptual or sign function of natural objects (and persons) is greatly influenced by what these objects do to or for man, and they also say that the sign function of objects is likewise dependent upon what other persons say or do in the presence of these objects or their symbolic equivalents. Thus, if a child learns the name of an object and if the child's parents behave in a characteristic manner (e.g., showing fear, approval, or anger) when the child utters the object's name, the child's future re-

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actions to the object itself are certain to be modified. Hence, Hallowell's emphasis upon the importance of knowing how the physical world is meaningfully defined if we are to understand its significance and potentialities for a particular person or group of persons. Just as there are some features of the physical environment that are common to all human beings and just as there are still other features that are relatively distinctive for a given social group, so also are there physical-environmental determinants of personality that are more or less unique for the individual. The fact that no two human beings can occupy the same point at the same time and that the world is never precisely the same on successive occasions means, as many philosophers have pointed out, that, in detail at least, the physical world is idiosyncratic for each individual. That "accidents," such as being burned or perhaps merely frightened by lightning, being struck by a falling tree, or stumbling over an unseen obstacle, have implications for subsequent personality trends can hardly be doubted. Cumulative influences stemming from the physical environment may also have distinctive consequences for groups or for particular individuals, but these have not been adequately analyzed. In some ways, the term "impersonal environment" is preferable to "physical environment" because the latter tends to have the exclusive connotation of topography, weather, and the like, whereas dwellings, furniture, and all human artifacts actually are a very important aspect of the external, objective, and nonhuman environment. These objects all acquire symbolic (including prestige) value for individuals, for social groups, and for whole societies. Both in the symbolic and in the immediate physical sense they are depriving or Ifrustrating agencies. We often speak as if deprivation and frustration were imposed on children only by their elders, but a high shelf which makes a coveted delicacy inaccessible or a gadget which cannot be manipulated will also interfere with a goal response. Societies and social subgroups vary widely in respect to the "material culture" sector of their environments. The effect of the total environment upon personalities may, following Murray (45), be called the "press." But, in spite of the subtle interactions of the different facets of environment to which we have been drawing attention, the "press" must be broken down into physical-environmental, social, and cultural elements. Of these abstractions the social is the most elusive. Although intimately interrelated, the social determinants of personality must be distinguished from the cultural. Man is, of course, only one of the many social ani-

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mals, but the ways in which social, as opposed to solitary, life modifies his behavior are especially numerous and varied. The fact that human beings are mammals and reproduce bisexually creates a basic predisposition toward at least the rudiments of social living. And the prolonged helplessness of human infants conduces to the formation of a family group. Although more a product of experience than of any inherent biological force, the in-group principle may also be listed as a universal social determinant. Certain universalistic social processes such as conflict, competition, and accommodation are given their specific forms under the influence of communal social determinants and cultural determinants. Thus, while there is a universal process of social interaction whereby the physically strong tend to dominate the weak, this tendency may be checked and even to some extent reversed by a cultural tradition which rewards intellectual strength more richly than physical strength. Or, the operation of the process may be modified by communal and role social determinants: attitudes toward women, toward infants, toward the old, toward the weak will be conditioned by age and sex ratios and by the general population equilibrium prevalent in a given society at a particular time. Analytically, the distinction between the social and the cultural is a most significant one. This is peculiarly true at the level of the idiosyncratic determinants. There are many forces of social interaction which influence personality formation and yet are in no sense culturally prescribed. As Mead (41, p. 141) has pointed out, all children (except multiple births) are born at different points in the parental life careers, which means that they have, psychologically speaking, somewhat different parents. Likewise, whether a child is wanted or unwanted and whether it is of the desired sex will also determine the specific ways in which its parents and others will treat it—even though the culture says that all children are wanted and defines the two sexes as of equal value. In specific cases, however, the social and cultural are, for the most part, almost inextricably mixed. Let us take as an example a case where "accidents" of the life history (idiosyncratic determinants) are superimposed upon both biological and cultural determinants. Even though identical twins may differ remarkably little from a constitutional standpoint and may also have very similar culturally defined experiences, unpredictable factors in the impersonal environment may affect them so that their social interactions are quite different. If, for instance, one of two such twins happened to be injured in an automobile accident and the other was not, and if the injured twin

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has to spend a year in bed, it is plausible to suppose that marked personality differences might result.4 But the variations in the social treatment which the bedridden twin receives will be partly determined by culture (the extent to which the ideal patterns say that a sick child must be petted, etc.), partly by extracultural factors: the mother's need for nurturance, the father's idiomatic variant of his culturally patterned role in these circumstances, etc. "Culture," though definitely an abstraction (cf. 30, p. 126), is like "heredity," a highly convenient conceptual construct. Indeed, culture is precisely one form of heredity—social as opposed to biological heredity (cf. 34, pp. 77-79, 85). Thus, just as we may speak of "constitutional determinants of personality," so are we justified in speaking of "cultural determinants of personality." This is not resorting to mysticism or to an' abstraction which is not reducible to its behavioral referents. Nothing is more certain and concrete than the fact of human teaching. An example will show, however, the justification for detaching the teaching itself from the actual teachers. If a random third of the parents of Cambridge, Massachusetts, were to die tomorrow and their children were to be socialized by their surviving relatives and friends in Cambridge, it may safely be predicted that what these children would learn—taking the group as a statistical whole—would be approximately the same as if their parents had survived. In other words, although culture is always mediated by individuals—and this fact must never be forgotten—it does, in a limited sense, have a supra-individual character. The existence and continuity of most of any culture does not depend upon the lives of any particular person or persons in that group. Indeed, in moderately stable societies, although the whole population of any one period will over a period of years die, the culture will have been transmitted to their descendants and will continue in existence with a modicum of change. One may compare with this the fact that the genes of persons now long dead continue to exert their effects upon the behavior of living descendants. Anthropology has made what is perhaps its most distinctive contribution by calling attention to the sparsity of universal cultural determinants of personality. It has shown that many social values which were formerly assumed to be common to all humanity are functions of a particular culture. But the cross-cultural analyses of the anthropologists have left a few universals. All societies have taboos on incest. All societies teach that it is "wrong" to murder members 4 The extent to which these differences persisted into adulthood would, to be sure, depend upon many factors, but it is unlikely that they would be counteracted entirely.

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of one's own social group. And all societies have as part of their culture the precept of loyalty to the in-group. In order for culture, in the sense of accumulated and transmitted discoveries and skills, to be maximally effective and useful to succeeding generations, its content must have a certain generality and common applicability. That most of the cultural determinants are of the communal and role types is obvious. Yet, in a sense, certain cultural determinants are idiosyncratic in their reference. In small societies, for example, there may well be but a single dwarf. One culture prescribes that a dwarf shall be laughed at, another that he be regarded with reverence as a supernatural being. Here again we must note the interdependence of the determinants. The effects of "accidents" upon the individual and upon the behavior of others toward him are influenced by culture and indeed by all the communal and role determinants. No society entirely fails to try to prepare individuals for the uncertainties as well as for the culturally predictable "certainties" of life. Most cultures contain preconceptions about the import of "accidents" and "misfortunes." It is, for example, definitely a part oi the traditional lore of some societies that disapproved conduct wrill be punished by "fate" in one way or another.5 Illness, untimely death, famine, deformity, defeat in war, floods, and other natural catastrophes are interpreted as causally related to previous action on the part of individuals or the group as a whole (20, 31). In other societies culture may not prescribe that misfortune shall follow socially objectionable behavior, but when misfortunes do occur, such causes may be looked for retrospectively. Still other instances might be cited in which culture provides magical interpretations of uncontrollable events; and each culture must, by virtue of slight uncontrollable and unpredictable deviations in what and how and by whom the individual person is socialized, have for the individual slightly private versions and overtones. But by its very nature culture must be less concerned with the variable than with the relatively constant experiences which human beings encounter, although, as we have seen, it is not entirely meaningless to speak of idiosyncratic cultural determinants of personality. Constants and Variables.—While the significance of biological determinants has been, and in popular circles still is, overestimated, there are some indications that social scientists are tending to give the same misguided unilateral evaluation to culture. The problem must 5 For an illuminating discussion of the relation between the concept of fate and parental influences, see Fenichel (9).

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never be structured as biological or cultural determinants. The prime point in the foregoing discussion is that physical-environmental, social, cultural, and biological determinants and their complicated interrelations must all be given due consideration. Finally, it must be continually realized that, from the point of view of the vertical columns in Table 1, some classes of determinants may be regarded as "constants," others as "variables." The idiosyncratic determinants can be called "variables" in contrast to the other three classes which, with fair precision, may be termed "constants" (either for all men or for social units of men—nations, communities, castes, classes, etc.). Because of personality typologies and folkloristic social stereotypes, the constants are not likely to be forgotten. But we sometimes overlook the forces operative in personality formation which cannot be predicted upon the basis of knowledge of a biological stock, a physical environment, a given culture, or the general properties of social interaction. They are the things that "just happen to people"—peculiar to each individual rather than more or less inevitable for all individuals who have a common heredity, share a physical environment, live in a society of a certain size and have other noncultural determinants of social interaction, and share a common culture. The potentialities for such happenings are obviously present in the system as defined by the communal and role determinants, but they are not prescribed by the total system for all individuals of a certain age, sex, class, or other social category. Individuals not only have biological and social experiences, but they have experiences which could not have been predicted from the nature of the human body or from membership in a specific society. Putting the conceptual scheme in a manner which cuts across both the constants and the variables, we have (a) the organism moving through a field which is (b) structured both by culture and by the physical and social world in a relatively uniform manner but which is (c) subject to endless variation within the general patterning, due to special or idiosyncratic determinants which are introduced by "accident" or "fate." e

The Components of Personality There are fashions in personality. Fashions that vary in time—like crinolines and hobble skirts—and fashions that vary in space—like Gold Coast loin cloths and Lombard Street tail coats. In primitive societies 6

Cf. Young (54, pp. 132-36) and Kluckhohn (29, esp. n. 6).

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everyone wears, and longs to wear, the same personality. But each society has a different psychological costume. Among the red Indians of the Northwest Pacific Coast, the ideal personality was that of a mildly crazy egotist competing with his rivals on the plane of wealth and conspicuous consumption. Among the Plains Indians, it was that of an egotist competing with others in the sphere of warlike exploits. Among the Pueblo Indians, the ideal personality was neither that of an egotist nor that of a conspicuous consumer nor that of a fighter, but that of the perfectly gregarious man who makes great efforts never to distinguish himself, who knows the traditional rites and gestures and tries to be exactly like everyone else. European societies are large and racially, economically, and professionally heterogeneous; therefore orthodoxy is hard to impose, and there are several contemporaneous ideals of personality. (Note that Fascists and Communists are trying to create one single "right" ideal—in other words are trying to make industrialized Europeans behave as though they were Dyaks or Eskimos. The attempt, in the long run, is doomed to failure; but in the meantime, what fun they will get from bullying the heretics!) In our world, what are the ruling fashions ? There are, of course, the ordinary clerical and commercial modes—turned out by the little dressmakers round the corner; and then la haute couture; ravissante personalite d'interieur de chez Proust; maison Nietzsche et Kipling: personality de sport; personality de nuit, creation de Lawrence; personalite de bain, par Joyce. A pragmatist would have to say that Ben Jonson's psychology was "truer" than Shakespeare's. Most of his contemporaries did in fact perceive themselves and were perceived as "Humours." It took Shakespeare to see what a lot there was outside the boundaries of the Humour, behind the conventional mask. But Shakespeare was in a minority of one—or, if you set Montaigne beside him, of two. Humours "worked"; the complex, partially atomized personalities of Shakespeare didn't. In the story of the emperor's new clothes, the child perceives that the great man is naked. Shakespeare reversed the process. His contemporaries thought they were just naked Humours; he saw that they were covered with a whole wardrobe of psychological fancy dress. Take Hamlet. Hamlet inhabited a world whose best psychologist was Polonius. If he had known as little as Polonius, he would have been happy. But he knew too much; and in this consists his tragedy. Read his parable of the musical instruments. Polonius and the others assumed as axiomatic that man was a penny whistle with only half a dozen stops. Hamlet knew that, potentially at least, he was a whole symphony orchestra. Mad Ophelia lets the cat out of the bag. "We know what we are, but we know not what we may be." Polonius knows very clearly what he and other people are, within the ruling conventions. Hamlet knows

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this, but also what they may be—outside the local system of masks and humours. To be the only man of one's age to know what people may be as well as what conventionally they are! Shakespeare must have gone through some rather disquieting quarter hours.7

Although in the literary rather than in the scientific mode, Huxley is here calling attention to some very real problems in personality theory. If the purpose of the first section was to avoid the pitfalls of an oversimple delineation of the determinants of the social stimulus value of individuals, the purpose of this section is to stress the necessity of treating the individual as an integrate in action. One must not confuse a few limited aspects of social stimulus value with the whole personality. In some circumstances, we react to men and women, not as unique organizations of experience, but as representatives of a group. In other circumstances, we react to them primarily as fulfilling certain roles. But if at times some facets draw our attention more than others, we must not lose sight of the fact that the personality, like the organism whose social stimulus value it represents, is a whole. Often the best way to avoid confusing a part with a whole is to become explicitly aware of the specific parts which may be abstracted from the whole. Let us therefore follow out in some detail the implications of the varying "psychological costumes" of different societies in space and in time and of the "Humours." The Universal Component.—In our preoccupation with the interesting differences which we note between individuals and personality types, we tend to forget that the phrase "a common humanity" is not altogether meaningless. The reaction which any human being produces in other human beings is different from that produced by any other animal or by any sort of inanimate entity or event. The folkloristic saying, "Why, that isn't even human" is based, as are so many commonplaces, upon a frequently overlooked but profound truth: the basic uniformities in physical appearance and behavior deeply condition the social stimulus value of all men for all other men. These stem from the universal (biological, physical-environmental, social, and cultural) determinants which have been reviewed in the preceding section and constitute what we may designate as the universal component in the personality of all human beings. By using the expression "all human beings," we tend to exclude from this 7 Aldous Huxley, Eyeless in Gaza (London: Chatto & Windus, 1936; New York: Harper & Bros., 1936), pp. 105-7.

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generalization those individuals who, because of idiocy, physical monstrosity, or social isolation and neglect, fail to qualify for responsible membership in their natural social group. Properly speaking, the universal component of human personality consists of those physical and behavioral traits which are accepted as normal and desirable in all human societies. The facts of personality which compose this universal component have been the subject of much speculation, but we have little scientifically verified information concerning them. We mention the universal component of personality in the present context partly for purposes of conceptual completeness and partly as a means of indicating important lacunae in our knowledge. The Communal Component.—That "the members of any given society tend to share more personality traits with other members of that society than with the members of other societies" is attested by common experience. If we are unfamiliar with Navaho Indians, we are likely to react to them first as Navahos rather than as individuals. Their first social stimulus value is largely in terms of those features of physical appearance, costume, and behavior which sets them off as representatives of a different society from our own. One frequently hears whites who have recently entered the Navaho country say, "I can't tell one Indian from another." Similarly, one hears Navahos who have had little experience with whites saying, "All white women seem alike to me. I just can't recognize one after 1 have met her." This diffuse generalization of the social stimulus value of members of a particular out-group certainly rests, in the first instance, upon similarities of total visual (and sometimes olfactory) impressions. Such also seems to be the basis of that rather remarkable phenomenon known as species cohesion in animals (cf. 55, pp. 11518). Human beings, however, fail to make strictly individual discriminations about both physical appearance and behavior, especially linguistic behavior. Even within a larger social unit, the reactor places the actor as the representative of a regional or class group on the basis of "accent" To a considerable degree, physical appearance and accent are reacted to only as symbols of a more thoroughgoing and deeply felt differentiation. What "sets off" our reaction in the first instance may be a combination of physical traits, but skin color, nose shape, and other physical features are in some cases closely associated with our experience of certain culturally determined varieties of behavior. The tendency toward uniformity in social stimulus value may be observed even between social groups where differences in physique

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and distinctive costume are slight and inconstant (for example, between Englishmen or Australians and Americans). In this case also, the first contacts with representatives of the alien society are more likely to have the character of culture-defining value than of persondefining value (cf. 48, p. 409). The statistical prediction can safely be made that a hundred Americans will display particular features of personal organization and behavior more frequently than will a hundred Englishmen of comparable age, social class, and vocational assortment. So great is the influence of culture that there is a grain of truth in Faris' (8, p. 7) statement that "Culture is the collective side of personality; personality the subjective aspect of culture." But this is rather less than a half-truth. Not only culture but also the other communal determinants—the common forces in the biological heredity and the physical and social environments—bring about that configuration of personality traits which the members of a given society tend to share. Since any organism is a whole and since in the last analysis the social stimulus value of the organism is a totality, we shall not call those aspects of social stimulus value which accrue to the individual as a member of a society the "communal personality" but rather the communal component8 of personality. The Role Component—But we must deal with "Humours" as well as with "psychological costumes." Still another closely related abstraction must be added if we are not to be misled by relatively surface resemblances between personalities. Under the influence of the role determinants, the communal component takes many variant forms. It is an induction from common experience that Englishmen occupying different statuses have different social stimulus values for the same persons. The peer's personality is not that of the cab-driver nor that of the retired Indian colonel. The personalities of American women tend to be distinguished by certain traits which appear much less frequently in the personalities of American men. When we meet new people at a social gathering, we are often able to predict correctly, "That man is a doctor." "That man certainly isn't a businessman— 8 In speaking of "the communal component of personality" we are getting at something quite similar to, though more inclusive than, Kardiner's (27) "basic personality structure." The adjective "basic" seems to us unfortunate and misleading. For idiosyncratic determinants do not enter into the formation of the "basic personality structure," and yet they are actually more "basic" in the sense that many of the biological idiosyncratic determinants exist prior to all cultural training. Moreover, if an Englishman came to this country when he was five and remained here, he would certainly acquire most of the American "communal component" which would be superimposed (i.e., "based") upon the structure arising out of constitution and his earlier socialization in England. However, Kardiner really means "basic" in the sense of "uniform" or "common to members of a group," and his conception is therefore closely related to ours.

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he acts like a professor." " H e surely isn't an artist or a writer or an actor." There is nothing mysterious about all this. As Linton (34, pp. 476-77) says: Each society approves and rewards certain combinations of qualities when they appear in individuals occupying particular statuses. Furthermore, it tries to develop these qualities in all the individuals for whom the particular statuses can be forecast. In other words, each society has a series of ideal personalities which correspond to the various statuses which it recognizes. Such status personalities are not to be confused with psychological types. In their definition societies do not go far below the surface. The status personality does not correspond to the total personality but simply to certain aspects of the content and more superficial orientations of the latter, i.e., to those elements of the total personality which are immediately concerned with the successful performance of the individual's roles.

These considerations explain the observed fact that the account of an individual's personality which we get from equally competent observers who have known him when he was carrying out different roles—in the home, in business, in the clinic, in his lodge—often fail to coincide in important particulars. Few individuals are "single, consistent personalities." Most individuals have "different faces" to put on for each situation that arises. There are not only, as John Dewey says, "occupational psychoses," there are also "occupational personalities" (cf. 24, 25), which is perhaps but a slightly different way of saying the same thing. Boas (2, pp. 88, 174) speaks of "organization personality." Merton (42) writes of "bureaucratic personality structure." Landes (32) even talks of the "summer and winter personalities" of the Ojibwa Indians. Other writers speak of "age and sex personalities," having in mind such phenomena as the following: the personality of an old doctor is different from that of a young one; the personality of the woman lawyer has typical differences from that of her male colleague. The differential aspects of personality manifestations which are reacted to and observed when the individual carries out the differing roles of his social life we shall call the role component. We shall not speak of the "role personality," for this implies that the personality is divisible, whereas it is a whole, separable only by abstraction. If the terms we use for our abstractions do not imply absolute divisibility but merely facets to which we may differentially react, we are less likely to forget that, when we speak of "personality," we are always necessarily referring to the individual as an integrate in action.

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The fact that a doctor has a bedside manner does not mean that he ceases to act as an American or in accord with the idiosyncratic core of his personality. We use the term "role" rather than "status" because the distinction which Davis (7, p. 310) makes between "status" and "office" is a useful one and because, as Davis also points out, the social stimulus value of the individual carrying out a role "is always influenced by factors other than the stipulations of the position itself." The relative weight of the role component in the social stimulus value of any person varies greatly according to the number of roles defined and the accent of the expectations enjoined by different cultures. Fromm's observations (15, pp. 41-42, 117, 205, 253) are acute: A person [in medieval society] was identical with his role in society; he was a peasant, an artisan, a knight, and not an individual who happened to have this or that occupation.... The "self" in the interests of which modern man acts is the social self, a self which is essentially constituted by the role the individual is supposed to play and which in reality is merely the subjective disguise for the objective social function of man in society.... The pseudo self is only an agent who actually represents the role a person is supposed to play but who does so under the name of the self. It is true that a person can play many roles and subjectively be convinced that he is "he" in each role. Actually he is in all these roles what he believes he is expected to be, and for many people, if not most, the original self is completely suffocated by the pseudo self.... When the general plot of the play is handed out, each actor can act vigorously the role he is assigned and even make up his lines and certain details of the action by himself. Yet he is only playing a role that has been handed over to him.

The Idiosyncratic Component—Alexander (1, p. 244) remarks that a persistent organization of trends and tendencies of the individual is formed early in life "by a combination of hereditary and domestic influences." He partially recognizes what we should call the "communal component" when he says, "These domestic influences differ enough from family to family to produce a wide variety of personality structures which might be rare in one civilization but common in another." But he correctly points out that only some of the "domestic influences" are "typical of contemporary society rather than peculiar to the individuals, whether parents or siblings, who exercise them." And Alexander is probably right in saying, "The individuality of parents has a greater influence upon the development of their children's personalities than convention and cultural tradition" (p. 243).

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Biological, cultural, social, and physical-environmental determinants all combine to produce the idiosyncratic component of personality. Smith is "stubborn" in his office as well as in his home and in a golf game. H e would have been "stubborn" in all social contexts if he had been taken to England from America at an early age and his socialization had been completed there. The idiosyncratic component always tinges the playing of roles. The social stimulus value of different individuals in the same society who occupy the same position (statuses and offices) varies. We verbalize such differences by saying, "Yes, Smith and Jones are both forty-five-year-old Americans, both small businessmen with about the same responsibilities and prestige—but somehow they are different." Each individual's patterned ways of perceiving, feeling, and behaving do have a characteristic organization which is not precisely paralleled by that of any other individual. For purposes of therapy and for certain research objectives, it is this uniqueness of personality which must be tenaciously accented. But for general scientific purposes both facts must be kept firmly in mind: the uniqueness of personalities and their resemblances. The idiosyncratic features are, as it were, imbedded in a matrix which is more public than private, and only the totality—not any one component—may properly be called the personality. Even though we live in a society where "who you are" rather than "what you are" counts, the role component is only one face of the self. On the other hand, the idiosyncratic component, like the communal and role components, is only one part of the individual's total social stimulus value. When Davis and Dollard (6, p. 11) speak of personality as "that behavior of an individual which distinguishes him from other individuals trained by similar social controls/' they do violence to the intricate interdependence of the three components. In the preceding section we called attention to the fact that in addition to universal and communal resemblances in the personalities of different human beings, there is another type of resemblance which cuts across the boundaries of groups but which is due to idiosyncratic rather than to universal determinants. This observation can be concretely illustrated. In general, Hopi Indians and white Americans have very different social stimulus value. But occasionally one meets a Hopi whose behavior, either by total impression or by some single reaction system, reminds one very strongly of the behavior of certain white men or women. Such parallels could originate from a similarity either in biological, physical-environmental, social, or cultural idiosyncratic determinants. A Hopi and a white man could both have a special endocrine imbalance unusual in the populations of both

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societies. Or both Hopi and white could have had long childhood illnesses which brought them each an exceptional amount of maternal devotion. While the effects of extra maternal care would have somewhat different effects according to the prevailing constellation of the other determinants, there would remain at least a segmental similarity which might well produce arresting resemblances in the two adult personality structures. Discrimination of the Components: Actors and Reactors.—It is not unenlightening to remember that in early Latin persona means "a mask"—dramatis persona is thus an actor who wears a mask in a play (cf. 23, esp. chap, xiii; 39). Etymologically and historically, then, a personality is the wearer of a mask. For those who are fairly well adjusted in their society, the communal and role components of the personality do tend to constitute disguises. Just as the outer body screens the viscera from view, and clothing the genitals, so the "public" facets of personality shield the private personality from the curious and conformity-demanding world of other persons—and usually, also, keep many motivations from the individual's own consciousness. The person who has painfully achieved some sort of integration and who knows what is expected of him in a particular social situation will produce those responses with only a slight idiosyncratic coloring. This is why the uniformities provided by the communal and role components can, in the case of "normal" individuals, be penetrated only by the long-continued, intensive, and oblique procedures of depth psychology. Only projective techniques will often bring out what the individual does not want to tell about himself and what he himself often does not know. Some of our analogies perhaps suggest that any personality may be dissected as one peels the layers off an onion. This is a crude and only very partially correct view. Sometimes the communal component is the outer "layer," sometimes the role component. This depends upon who the observer is. For social stimulus value is a function both of actor and of reactor. If the actor is from a society markedly different from that of the observer, his social stimulus value is at first almost completely confused with the communal component. What are actual peculiarities of the individual may be attributed to a stereotype for that society. The role component is hardly perceived at all unless the reactor is familiar with social differentiations in the other society. Roles can be discriminated with refinement only if the "audience" can appreciate differences. The delicacy of "identification" or "placement" depends on this. Thus we see why evaluations of out-groupers as individuals are always more or less inaccurate.

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Here we have one important aspect of "race prejudice"—individuals are judged on the basis of stereotypes. Discriminations are not sensitive. The kind of person one is taken to be is determined entirely by the kind of people that one habitually has around one. When one first meets a new person in one's own society, particularly if the person be from an occupational group sharply different from one's own or if the situation be an unfamiliar one, the stimulus value of the person is likely to derive primarily from the role component. If, however, one wants really to comprehend the total personality, one must "get behind" this front, temporarily stripping off (but not forgetting) the outer layer which is the totality of responses expected of the individual (for example, as young man, as lawyer, as lawyer dealing with female client, etc.). Before the student can get to the idiosyncratic component, he must also "factor out" the communal component. Apart from the fact that the subject is thirty years old, a man, and a lawyer, he is also an American. Many personality traits he will also share with American men, with American old people, with barbers and factory workers. Making the distinctions between universal, communal, role, and idiosyncratic components is not a mere exercise in sterile taxonomy. Clarity and consistency in these discriminations are essential to sound work in the "culture and personality" field. Otherwise we shall continually run the danger of ascribing to some known "accident" of the individual's life history a trait which he actually shares with almost all other Americans who have not been subjected to that eventprocess at all. Or we shall interpret a person's behavior in a given situation as reflecting certain trends in his "core personality" (idiosyncratic component) when he is only conforming, very acceptably, to social expectations of performance of that role. Only after careful scrutiny can behavior be taken at its face value as providing clues to the idiosyncratic variant of socially approved norms which any human organism's action represents. All of us, even clinicians, are sometimes "taken in" by the masks of the communal and role components. We visit a doctor in his office, and his behavior conforms so perfectly to our expectations that we say, often mistakenly, "There is indeed a well-adjusted personality." We extrapolate from his behavior in his role of physician and infer, "There is a respectable citizen if there ever was one. Obviously his private life also conforms to prevalent standards." The reader may have wondered why we have designated four personality components corresponding, respectively, to the universal, communal, role, and idiosyncratic determinants of personality but

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have not equally discriminated components which correspond to the biological, physical-environmental, social, and cultural determinants. As we have already indicated, the latter seem to us to represent abstractions of a higher order than do the universal, communal, role, and idiosyncratic determinants; and common experience shows that there are no personality components or traits stemming from these second-order determinants which are so easily discerned as are those which derive from the first-order determinants. This is because, in all save newborn organisms, the biological and environmental aspects of personality manifestations can hardly be disentangled. All geneticists are agreed today that "traits" are not inherited in any simple sense: observed characters of growing and matured organisms are, at any given point in time, the product of complex interactions between biologically inherited potentialities or trends and environmental influences. On the other hand, it is possible by simple observation and induction to determine the features of personality shared by the members of a given society, by those playing a common role, etc. Freud (cf. 9), Murray (45), and other clinical writers have proposed personality subdivisions which are suggestive of our four secondorder determinants, and the learning theory elaborated at Yale University by Hull (1943) and by Miller and Dollard (1941) can also be forced to yield to an approximate parallelism. This, however, is a complicated problem which cannot be adequately discussed here but has been considered in some detail elsewhere (44). Summary Starting with May's definition of personality as an individual's "social stimulus value," we have sought to delineate a conceptual scheme which would accommodate all of the determinants of social stimulus value and which would also systematically order the components of "personality" as thus defined. A survey of the evidence indicates that the determinants of personality fall naturally into four categories: universal determinants, communal determinants, role determinants, and idiosyncratic determinants. Further analysis shows that these categories, which may be represented as the headings of four vertical columns (Table 1), are cut across horizontally by another fourfold classification of determinants which includes: biological determinants, physical-environmental determinants, social determinants, and cultural determinants. There thus emerges an exhaustive matrix of sixteen subcategories or "cells," to one of which any naturalistic determinant of personality can be logically assigned.

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When the four vertical or first-order determinants of personality are examined, it is found that they rather exactly parallel four components or "layers" of personality which are tacitly assumed, if not explicitly distinguished, by contemporary social science, namely, the universal component, the communal component, the role component, and the idiosyncratic component. Personality components which similarly correspond to the horizontal or second-order determinants of personality are less readily identified, although the "mental anatomy" of psychoanalysis, with its id, ego, and superego categories, may be said to parallel in a very rough way the biological, physical-environmental, social, and cultural categories of personality determinants. We should like to stress our position that we do not in any sense claim an absolute superiority for our terminology. We acknowledge, for example, the utility of the id, ego, and superego divisions within the psychoanalytic frame of reference. We are aware of the difficulties of the "social stimulus value" definition of personality, although we strongly disagree that this definition implies that an individual has "two personalities" because his effects upon two observers are markedly different. Rather, we insist, this datum indicates only that the actor-reaction equation must be considered in all personality studies. Thus, when a person does produce divergent effects upon two reactors, this almost always reflects varying facets in the personal organization of both actor and reactor. We do suggest that our conceptual scheme is in accord with many recent studies in this field. Our "communal personality," for instance, is very similar to Fromm's (15, p. 277 ff.) "social character." Finally, our realization that all of the personality determinants and all of the personality components are abstractions must be emphasized again. Concretely, we can only follow the whole organism as an integrate in action (cf. 11). REFERENCES 1. ALEXANDER, F. Our age of unreason. Philadelphia: J. P. Lippincott Co., 1942. 2. BOAS, F. The mind of primitive man (2d ed.). New York: The Macmillan Co., 1938. 3. BRUCH, H. Obesity in childhood and personality development. Amer. J. Orthopsychiat, 1941, 11, 467-75. 4. BRUNSCHWIC, L. A study of some personality aspects of deaf children. New York: Teachers College, Columbia University, 1936. 5. CABOT, P. S. de Q. The relationship between characteristics of personality and physique in adolescents. Genet. Psychol. Monogr., 1938, 20, 3-120. 6. DAVIS, A., and DOLLARD, J. Children of bondage. Washington, D. C.: American Council on Education, 1940.

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7. DAVIS, K. A conceptual analysis of stratification. Amer. social Rev., 1942, 7, 309-22. 8. FARIS, E. Culture and personality among the forest Bantu. Publications of the American Sociological Society, 1934, 28. 9. FENICHEL, O. Outline of clinical psychoanalysis. New York: W. W. Norton & Co., Inc., 1934. 10. FORD, C. S. Society, culture, and the human organism. J. gen. PsychoL, 1939, 20, 135-79. 11. FRANK, L. K. Structure, function, and growth. Phil. Sci., 1935, 2, 210-36. 12. FREEMAN, G. L. Introduction to physiological psychology. New York: The Ronald Press Co., 1934. 13. FRIES, M. Factors in character development, neuroses, psychoses, and delinquency. Amer. J. Orthopsychiat., 1937, 7, 142-82. 14. . Interrelated factors in development. Amer. J. Orthopsychiat., 1938, 8, 726-53. 15. FROMM, E. Escape from freedom. New York: Rinehart & Co., Inc., 1941. 16. GESELL, A. The method of co-twin control. Science, 1942, 95, 446-49. 17. HABBE, S. Personality adjustments of adolescent boys with impaired hearing. New York: Teachers College, Columbia University, 1936. 18. HALDANE, J. B. S. Anthropology and human biology. In Compte-rendu, Congres International des Sciences Anthropologiques et Ethnologiques, 1934, pp. 53-65. 19. HALLOWELL, A. I. Handbook of psychological leads for ethnological field workers. Mimeographed, 1935. 20. . The social function of anxiety in a primitive society. Amer. sociol. Rev., 1941, 6, 869-82. 21. HENDERSON, L. J. Blood, a study in general physiology. New Haven, Conn.: Yale University Press, 1928. 22. HOMANS, G. C. English villagers of the thirteenth century. Cambridge, Mass.: Harvard University Press, 1941. 23. HORNEY, K. New ways in psychoanalysis. New York: W. W. Norton and Co., Inc., 1939. 24. HUGHES, E. C. Personality types and the division of labor. Amer. J. Sociol., 1928, 33, 754-68. 25. . Institutional office and the person. Amer. J. Sociol., 1937, 43, 404-14. 26. JOST, H. Some psychological changes during frustration. Child Develpm., 1941, 12, 9-15. 27. KARDINER, A. The individual and his society. New York: Columbia University Press, 1939. 28. KLINEBERG, O. Race differences. New York: Harper & Bros., 1935. 29. KLUCKHOHN, C. Theoretical bases for an empirical method of studying the acquisition of culture by individuals. Man, 1939, 39, No. 89. 30. . Patterning as exemplified in Navaho culture. In Spier, L. (ed.), Language, culture, and personality. Menasha, Wis.: Sapir Memorial Publication Fund, 1941. 31. . Myths and rituals: a general theory. Harv. theol. Rev., 1942, 35, 45-80. 32. LANDES, R. The personality of the Ojibwa. Cult, and Pers., 1937, 6, 51-60. 33. LEVY, D. Psychosomatic aspects of some aspects of maternal behavior. Psychosom. Med., 1942, 4, 223-27. 34. LINTON, R. The study of man. New York: Appleton-Century-Crofts, Inc., 1936. 35. . A neglected aspect of social organization. Amer. J. Sociol., 1940, 45, 870-87. 36. . Age and sex categories. Amer. sociol. Rev., 1942, 7, 589-604. 37. LYND, R. Knowledge for what? Princeton, N. J.: Princeton University Press, 1939.

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38. LYNN, J. G., and LYNN, D. R. Face-hand laterality in relation to personality. /. abnortn. soc. Psychol, 1938, 33, 291-323. 39. MAUSS, M. Une categorie de l'esprit humain: la notion de Personne, celle de moi. / . R. anthrop. Inst., 1939, 68, 263-83. 40. MAY, M. A. A comprehensive plan for measuring personality. In Proceedings and Papers of the Ninth International Congress of Psychology. Princeton, N. J.: The Congress, 1930. 41. MEAD, M. Growing up in New Guinea. New York: William Morrow & Co., Inc., 1930. 42. MERTON, R. K. Bureaucratic structure and personality. Social Forces, 1940, 18, 1-10. 43. MILLS, C. A. Climatic effects on growth and development, with particular reference to the effects of tropical residence. Amer. Anthrop., 1942, 42, 1-14. 44. MOWRER, O. H., and KLUCKHOHN, C. Dynamic theory of personality. In HUNT,

45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55.

J. McV. (ed.), Personality and the behavior disorders. New York: The Ronald Press Co., 1944. MURRAY, H. A. Explorations in personality. New York: Oxford University Press, 1938. NEWMAN, H. H. Multiple human births. New York: Doubleday & Co., 1940. RICH, G. J. A biochemical approach to the study of personality. /. abnortn. soc. Psychol., 1928, 23, 158-75. SAPIR, E. The emergence of the concept of personality in a study of culture. /. soc. Psychol., 1934, 5, 408-15. SCHILDER, P. The sociological implications of neuroses. / . soc. Psychol., 1942, 15, 3-23. SHELDON, W. H. The varieties of temperament: a psychology of constitutional differences. New York: Harper & Bros., 1942. SHERIF, M. A study of some social factors in perception. Arch. Psychol., N. Y., 1935, No. 187. SNYDER, L. H. The principles of heredity (2ded.). Boston: D. C. Heath & Co., 1940. WOODWORTH, R. S. Heredity and environment. Soc. Sci. Res. Coun. Bull., 1941, No. 37. YOUNG, K. Personality and problems of adjustment. New York: AppletonCentury-Crofts, Inc., 1941. ZUCKERMAN, S. Functional affinities of man, monkeys, and apes. New York : Harcourt, Brace & Co., Inc., 1933.

Chapter 7 WHAT IS NORMAL BEHAVIOR? By

O. HOBART MOWRER, PhX). 1

First Group Discussion Chairman: It is almost two years now since our discussion group held its first meetings. At that time, you will recall, we were interested in gaining a better understanding of the concept of culture.2 It is proposed that in the present series of meetings we shall consider the question: What is normal behavior ? I am sure we are all aware of the importance of this question, but I imagine we are also all impressed by the many difficulties implicit in it. What we can hope to accomplish by way of answering the question in any definitive sense will be modest at best, but at the same time there is reason to think that our efforts may not be altogether unrewarding. Perhaps the kind of cooperative, interdiscipline approach to which our group is dedicated will enable us to resolve at least certain facets of the problem which have not readily yielded to the more conventional, segmental type of analysis. From your presence here this evening, I assume that all of you received the written announcement of the meeting and of the proposed topic of discussion. And if our earlier experience is a reliable guide, I can also assume that all of you have done some thinking and reading on the topic from the standpoint of your own particular field of specialization. In keeping with our established practice, I shall not call upon anyone for a formal speech but will simply throw the meeting open for informal, spontaneous discussion. 1

Many of the ideas, arguments, and references contained in this chapter have

come from students in a graduate course in mental hygiene. My indebtedness and gratitude are hereby acknowledged to: Rosine Bernheim, T. S. Chang, Mary B. Hutcheson, Allyn Johnson, Elizabeth Z. Johnson, Winifred S. Lair, Ellen Lane, Jean Laplanche, B. K. Moore, Ruth W. Nerboso, Marjorie D. Sanger, J. C. Stanley, Jr., John N. Stauffer, John W. Suter, Jr., U. E. Whiteis, Leta Fulton Whitney, and Elizabeth C. Wilson. I am also grateful to Professor Clyde Kluckhohn and to Mr.2 and Mrs. William G. Perry for a number of constructive suggestions. A digest of the group's discussions of this topic has been reported by Kluckhohn and Kelly (22). 136

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Statistician: I should like to be the first to point out that my particular specialty is perhaps limited in respect to what it can contribute to the ultimate solution of our problem; but this contribution is so explicit and in certain respects so basic that I venture to open the discussion. I find that in textbooks on abnormal psychology it is a common practice to introduce the concept of normality by first relating it to the statistical facts of "averageness" and "unusualness." Many psychologists, in fact, speak of "abnormal" and "unusual" personal characteristics as if the two terms were equivalent; and I find that a number of psychiatrists likewise place heavy emphasis in this connection upon "deviation from the average." For example, Cobb has said: "One must accept the fact that 'normal' is a range of values about the mean of a distribution curve. The average man and those near him are normal, the most 'perfect' specimen (if one can imagine such a specimen, and perfect for what?) would be far from normal" (6, p. 129). 3 I believe that I am therefore justified in proposing the purely statistical definition of normality as the starting point for our discussion. 1000 T 800 ••

600-• 13

o £400--

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FIG. 12. A frequency polygon of heights of 6,194 adult English men. The mean Hes at about 66.9 inches, and the vertical lines to the right and to the left of the mean indicate the approximate limits of the "normal range." After Vernon (40, p. 15). By permission of The University of London Press, publishers of P. E. Vernon, The measurement of abilities (1940).

In established statistical parlance, the "norm," in an array of individuals who vary with respect to some measurable characteristic, 3 Reprinted with permission of the Harvard University Press, publishers of Borderlands of psychiatry (1943).

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such as height or intelligence, is usually taken to mean the "central tendency." Thus, in this curve which I have prepared (Figure 12), we see the range and distribution of heights in an unselected population of English men, with a mean of 66.9 inches and with a "normal range" as indicated. Individuals whose height places them either above or below this range may be said to be "abnormal" with respect to height—in the literal sense of ab-normal, i.e., away from the norm. Where the line of separation between so-called normality and abnormality shall be drawn is, of course, usually quite arbitrary. A common convention is to mark off a point on the distribution which is one standard deviation above the mean, and a like distance below, and to designate the intervening area as the normal range. In a distribution that conforms to the common "bell-shaped" type of curve, this range will include about 68 per cent of all the cases, with roughly 16 per cent falling above and an equal number falling below this range. However, it is usually understood that the distribution is on a continuum and that, for example, a "low normal" score is different only in degree, not in kind, from a nearly equal score that happens to fall in the area just outside the so-called normal range. Rarely does one think of such a line of demarcation as being in any way categorical or absolute, although important practical decisions may depend upon whether a given individual's score falls upon one or the other side of such a line. And in this sense it seems to me that the statistical emphasis has been very helpful; it tends to emphasize the continuity rather than the discreteness of individuals who, on whatever grounds, are classified as normal or abnormal. Sociologist: I was pretty sure that the statistical point of view would be introduced at an early stage in the discussion so I, too, have brought along a curve. Since it is commonly regarded as undesirable for a person to be extremely tall or extremely short, the foregoing illustration of the concepts of normality and abnormality seems to work well enough. But if we take, not height, but, for example, intelligence as the basis for such an analysis, we encounter a serious complication. My curve (Figure 13) shows the distribution of intelligence scores earned by 1,600 ninth grade American school children. Here, again, there is a central tendency, a normal range, and two dwindling extremes. But although it is reasonable to refer to one of these extremes as representing individuals with "abnormally low" intelligence, it seems a strange twist of language to refer to the opposite extreme as representing individuals with "abnormally high" intelligence. It does not, however, seem at all remarkable if we speak of these children as having unusually high intelligence—a fact

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which focuses attention upon a wide variety of situations in which there is by no means a one-to-one correspondence between the unusual and the so-called abnormal.

30

20

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FIG. 13. A frequency polygon of intelligence scores of 1,600 ninth grade students, as determined by nine different tests. The scores are plotted so that the mean score equals zero. The "normal range" is indicated by the two vertical lines to either side of the line indicating the mean. Adapted from W. F. Dearborn, Intelligence tests (1928) (8, p. 22), by permission of Houghton Mifflin Co., publishers.

Now sociologists and social psychologists have long been aware of this difficulty and have worked out another way of dealing with the problem which— Educator: If I may interrupt for just a moment, I should like to register another objection to the statistical definition of normality. You will notice that our statistician drew his example from data based upon the heights of English men. By his criterion, many English women would be "abnormal" with respect to height, although they might not be unusually short for women. The same point could be made with respect to the Pygmies of Africa and the Negrillos of Malaysia. And, of course, when we go from adults to children, the case is even more striking: what is normal height for a child ten years old would certainly be abnormal for an adult of either sex. This point is, of course, fully recognized in our definition of the I-Q. as a function of the individual's age. The problem is here solved by talking, not of "normal intelligence" in any general sense, but in terms of what is normal or usual for a child of a particular age. In other words, we separate children into a number of different groups or "populations" and then speak of a given individual as normally or not normally intelligent with respect to the age-group into which he falls. Practically, this type of procedure seems to work out all right in many instances, but I do not regard it as affording a logical solution to our problem. F o r example, educators have often felt it undesirable

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to have children with a wide range of intelligence in the same classroom and have tried to get around the difficulty by means of "homogeneous grouping." By this device the children in a given grade are segregated into two, three, or possibly more groups, according to their intelligence. Thus, a child with an I.Q. of 80 may be statistically abnormal with respect to the average intelligence of all the children in his grade but not abnormal with respect to the average of his particular "homogeneous group." However useful this procedure may be pedagogically, it points to a sobering problem logically, namely, that you can make almost anything or anybody "normal" if you are only willing to juggle sufficiently the group or classification into which the object or individual falls. In the ultimate case, you can say, in fact, that everything is "normal" with respect to itself, i.e., if you assume that each individual is sui generis. My point is one which has been well made by John Kendrick Bangs in his poem, "The Little Elf," which ends with the familiar lines: "I'm quite as big for me," said he, "As you are big for you." Physician: I should like to second what has just been said by noting that of all the persons in the world who, for example, have cancer, most of them may be said to be "average cases of cancer," but this fact hardly makes them healthy, which is the sense in which I am inclined to think of normality. Or, to make the same point with another example: we are accustomed to speaking of the inmates of mental hospitals and prisons, respectively, as insane and criminal; and with respect to each of these categories there are many individuals who are quite run-of-the-mill, "average," "usual," but hardly "normal," I should think. Psychologist: I should like to hear the rest of what our Sociologist was saying, but before he continues I want to raise this question: Does it make any sense, really, to talk about a given person being either normal or abnormal in any comprehensive way ? Must we not always speak of a person as normal or abnormal in respect to some specific, measurable characteristic? Incautious writers sometimes refer to the "measurement of personality" as if "personality" or "a person" could be gauged or rated in terms of a single variable, on some one master scale. More careful usage demands that we speak instead of "measurements of personality," for personality has many dimensions; and there is no one unit of measurement, or scale, that is applicable to all of them. In consequence, it is common practice on

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the part of many experts in my field to test or rate a given individual with respect to several different characteristics, and then to assemble the results in the form of a "profile" or "psychograph." Here (Figure 14) is an example which I thought the group might find interesting. o

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RATINGS ro u

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Energy Endurance Control Coordination Concentration Persistence Visual Discrimination Space Perception Accuracy Understanding Observation Intelligence Judgment Language FIG. 14. A profile or psychograph showing one individual's ratings on a variety of performances. Such a graph has to be evaluated in terms of its total pattern. Reprinted and adapted from M. S. Viteles, Industrial psychology (41, p. 153), with the permission of the author and W. W. Norton & Co., publishers.

This method of defining and dealing with the concept of personality immediately shifts the problem of normality from the purely quantitative to the qualitative plane; for who, on the basis of a psychograph, can say, in any over-all mathematical sense, that one person is normal and another is abnormal ? The difficulty is, of course, that one cannot add, mathematically, two units of Energy here with five units of Persistence there, or either of these with one or three units of Intelligence. In practice, a composite graph of this kind is used not so much for determining personal normality or abnormality in any over-all sense as it is for ascertaining whether a given individual seems to "fit" or "match" specifications which have been drawn up for a particular type of employment or for some other purpose.

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Philosopher: In this connection it is interesting to recall Emerson's theory of compensation, according to which each individual, in his totality, is equal to every other individual, since as Emerson assumed, a deficit in one area tends to be offset by a special advantage or virtue in another. Such thinking seems to be more of a prolegomenon to the theory of democracy than a statement of empirically verified fact. But it is also worth noting that the psychologist, Alfred Adler, has come out with a somewhat similar notion, which I should think might be termed the theory of "reactive compensation." According to this writer, a defect or inferiority in one area initiates compensatory strivings which often succeed not only in counteracting the defect but in producing extraordinary strengths and accomplishments (1). Psychologist: One other point I wanted to make is this. Statistically minded investigators, aware of the difficulties we have just been considering, have sometimes sought to isolate a single measurable attribute as the crucial one in determining personal normality or the lack of it. Various attempts have been made to measure what is commonly termed "nervousness," or more technically "emotional instability," by means of questionnaires. These investigations have recently been reviewed by Mailer (24), and I won't try to describe them here. But perhaps the earliest attempt to get at this variable by means of behavioral observation—and I remember that our question is : What is normal behavior?—was reported by Olson (30) in 1929. By means of a careful definition and accurate recording of specified "nervous habits" in children, this writer obtained data indicating "that the amount of nervous habits in a given population takes the form of a continuous distribution. The evidence suggests that the problem of nervous habits is the problem of every child, just as are such matters as weight, height, and educational achievement" (30, P- 90). It is interesting to note that Olson found no reliable correlation between a number of pencil-and-paper tests of "personality" and the incidence of "nervous habits" observed in his subjects. As the author points out, "the general intelligence factor makes the interpretation of scores on personality tests of the paper-and-pencil type a difficult matter" (p. 90). The scores on such tests tend to be invalidated "by the tendency to what has been called the 'intellectualization of response' on the part of children when giving a subjective report" (p. 90), 4 i.e., by the tendency to give what they believe to be a "right" answer rather than the "true" one. * Reprinted with the permission of the University of Minnesota Press, publisher of W. C. Olson's The measurement of nervous habits in normal children (1929).

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Educator: I think I can extend this argument. A few days ago I came across a study, reported by Tiegs and Katz (39), in which 100 college students were randomly selected from a much larger group and were then observed and rated with respect to fifteen evidences of "nervousness." The results are shown in this graph (see Figure 15). 25-r

1 2

3 4

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6 7 8 9 10 11 Number of Symptoms

FIG. 15. Incidence of symptoms of "maladjustment" in 100 unselected college students. Note that these symptoms tend to be normally distributed. After Tiegs and Katz (39, p. 66). From Ernest W. Tiegs and Barney Katz, Mental hygiene in education. Copyright 1941, The Ronald Press Company.

The great majority of the students manifested between seven and thirteen of these traits or mannerisms, one manifested only one such trait and one manifested all fifteen. It would thus appear that "abnormality," in the sense of "nervousness," is more or less normally distributed; and from a purely statistical standpoint the individual who showed only one of these traits would be just as "abnormal" as the one individual who showed all fifteen of them. The authors of this report may be correct in their statement that "identifying and tabulating specific evidences of nervousness produce a more objective basis for determining the probable normality of behavior than does the purely subjective method" (39, p. 67). Yet one wonders how valid such a procedure is, not only in respect of the statistical point I have just made, but in yet another way. Do we, in point of fact, have any proof at all that children—or, for that matter, adults—who are "fidgety" are necessarily less well organized personally or more likely to succumb to real mental disease than are quieter, less physically active individuals?

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(At this point the Biologist, the Psychoanalyst, and the Psychologist all started to speak, but the Chairman interrupted.) Chairman: Gentlemen, our previous meetings have shown that one of the dangers in this type of discussion is that important lines of thought may become sidetracked and that our deliberations may lack form and continuity. As chairman, I am therefore going to bring the discussion back to what seemed to me to start off on an orderly and promising line of analysis. We began with a statement of, and a number of objections to, the purely statistical concept of normality. Our sociologist then started to offer some sort of alternative proposal. I wonder if we might now return to what he was going to say. Sociologist: I am glad to have this opportunity to continue, for I believe that what I was going on to say is important and that it will open up new avenues of thought. 75.5%

22%

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FIG. 16. Behavior of 2,114 motorists at corners with cross traffic and with boulevard stop signs. After F. H. Allport (3, p. 228). This heavily skewed distribution forms a J-curve. By permission from Psychology at work, edited by Paul S. Achilles. Copyright, 1932. McGraw-Hill Book Co., Inc.

As we have seen, statistical illustrations of the concept of normality are usually drawn from distributions that conform to the well-known bell-shaped curve. But we find that in respect of many characteristics which are most interesting to students of social behavior, human beings form what F. H. Allport and his students refer to as a "J-curve." Let me illustrate this point by means of two diagrams. In the first of these (Figure 16) is represented the behavior of motorists at a street crossing where there was a stop sign. Here it will be seen that 75.5 per cent of the motorists came to a full stop and 22 per cent more proceeded very slowly. Only 2.5 per cent of all the drivers were observed to slow down only slightly or not at all.

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From data of this kind one gets a new notion of what is "normal." Here it is apparently not so much a matter of the average as of the ideal. Here it is less a question of "is" and more a question of "ought." In this type of analysis, the criterion of normality may be subsumed under the concept of social conformity. 37%

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12% Very Slow

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FIG. 17. Behavior of 208 motorists at corners with cross traffic but with no stop signs. After F. H. Allport (3, p. 228). This distribution gives a roughly bell-shaped curve. By permission from Psychology at work, edited by Paul S. Achilles. Copyright, 1932. McGraw-Hill Book Co., Inc.

That the J-curve is often merely a so-called normal curve that has been "pushed out of shape" by the pressure of social rules or laws is indicated by my second diagram (Figure 17). Here one sees the behavior of motorists at an intersection comparable to the first one but where there was no stop sign. Here the distribution of motorists' behavior follows the classical statistical pattern. But it is important to note that comparatively few of our actions may be said to follow the principle of laissez faire; most of our behavior is constantly impinged upon and shaped by social forces, which may be subtle or blatant but are ubiquitous and powerful. The question of conformity and nonconformity, therefore, seems to me to be much more central to our problem than is the mere matter of averageness, particularly if by average we think of being "in the middle," about equally distant from two extremes. In many situations of the type which I have illustrated, the extreme position of full conformity is the "normal" one. Philosopher: I am not sure I am keeping up with all of the technical implications of what is being said, but I must say that I like the general point of view which has just been suggested. The trouble, as it seems to me, with scientists is that they are always talking about the facts, the bare facts, and have nothing to say about ideals and values. It seems to me that the best type of person—whom I would say was also the most "normal" type of person—is one who is strongly identified with the total human enterprise, one who is striving to im-

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prove the lot of mankind, one who does all he can to contribute to his society and make it "go." Lest you be inclined to dismiss this point of view as merely a philosopher's whim, let me cite two psychologists in support of my position. Alfred Adler, whom I referred to earlier, has laid great stress upon the individual's relation to mankind as a whole (2). Adler maintained that the crucial consideration in determining human normality is whether the individual is an asset or a burden to society and whether he is or is not contributing to the progressive development of man. And I also find that Roback (36), in his volume entitled Character, has placed a similar emphasis upon what he calls "absolute normality," i.e., the condition of being ultimately proved "right" by continuing human experience, regardless of how unappreciated or ridiculed one may be at a given time or place. Anthropologist: I agree that scientists, particularly social scientists, cannot afford to keep on indefinitely insisting that science has nothing to do or say about matters of value, ethics, ideals. For the last three or four hundred years science has been steadily cutting the ground from beneath many of the great myths of our race, and yet when the layman turns to the scientist and asks, "What shall I believe instead?," the scientist shrugs and replies, "That's your affair, not mine." Actually, these matters of ethics and value are of vital, everyday concern to men and women, and we social scientists and psychologists are not going to have a really adequate theory of the self or of society, nor are we going to be of much practical use, until we are willing to come to full grips with these so-called "problems of value." I have some views as to how this can be done, but they would take us too far afield for present purposes. What I particularly want to point out now is how tenuous is the basis just offered as a criterion of normality. What about stupid laws, which it is one's moral duty to oppose and defy ? Where would the world be without the radical, the innovator, the reformer ? As Shaw has suggested (albeit a little whimsically), even the criminal may have social utility. Social customs and laws have to be changed from time to time; imagine what would happen if we took slavish conformity as our ideal. And to make my point in a different way, suppose you have a person reared in one society who then goes to another society, a society with a very different culture. You can hardly expect such a person suddenly to become a very different sort of individual the moment he crosses the frontier into the new country, and yet if he doesn't, he will, by this definition, suddenly become "abnormal." At any given time, there are always thousands of foreigners here in America, and do we look upon them

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as abnormal just because they have different ideals and standards? And what about the easily conceived case in which a whole culture may be said to be unhealthy, abnormal ? Conformity in this case may insure abnormality, not normality. Philosopher: I am not prepared to defend conformity as the ultimate basis of normality. I think personal consistency is a more valid guide than conformity per se—but I do want to say how opposed I am to one thing the preceding speaker has just said. He says we ought to oppose stupid laws by disobeying them. This is a point of view which I think has done a great deal of harm. We have ways to change laws in this country if they don't work, and this is not done by disobeying them. In my judgment the most effective kind of "radical" is a man (or woman) who has made all the renunciations that his society asks him to make, has accepted his full share of personal and social responsibility, and then steps forward to make his criticisms. The trouble with most self-styled radicals is that they are immature, irresponsible individuals who don't want to grow up and who cavil against society instead. Lenin obviously had this in mind when he said that the curse of a revolutionary movement is that it always attracts as followers a lot of people who are still adolescent in their mentality and social outlook. And I suspect that something of a similar nature might be said about neurotics, although I am not sufficiently informed technically to be more explicit on this score. Theologian: I feel a little lost in this discussion, but there is one thing I should like to say. Traditionally, we theologians haven't been much concerned with the concepts of normality and abnormality; we have instead been preoccupied with the problem of good and evil. Yet I feel that the two things are not unrelated. It may be true that some of our most revered and inspired religious leaders have been "abnormal" in terms of modern psychiatric standards; but I can't escape the conviction that there is an important connection between what we theologians mean by goodness and virtue and what you scientists are trying to get at in this discussion of so-called normality. In my long experience with people in my parish, I have repeatedly observed that happy people are, in the main, the good, virtuous people. It will be clear to you that what I have just said was suggested by the preceding discussion of the problem of conformity. W e theologians agree with the sociologists and others about the importance of conformity as a basis for normality and happiness; but the issue is, conformity to what ? You scientists say, conformity to the standards and ideals of one's social group; we say, conformity to the Will of God. And I naturally believe we are in the right.

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Anthropologist: Actually, there is less difference between the two points of view than one may at first suppose. The student of comparative sociology soon comes to see that, for any given people, the Will of God (or gods) is simply the most basic and oldest edicts of culture. But it makes a great deal of difference how one interprets what, in the final analysis, is one and the same thing. Without going into the point at all fully, let me merely remark that it seems to me that some of our most distressing social and personal difficulties today come from the fact that a lot of people still think of moral law, ethics, and values as completely pre-established by divinity. The fact is, as we read it from the records of man's history, that morality and ideals have been slowly and painfully evolved, and many of our present difficulties stem precisely from the fact that morality and ideals have not, in certain respects, yet evolved far enough. I am thinking particularly of our need for a "new morality," leading to the prevention of war, in the international sphere: but other examples could also be given. So long as we think that all wisdom and virtue have already been revealed to man, just so long will we fail to come to realistic grips with some of our most urgent developmental problems. Lawyer: I should perhaps stay out of this, but I just want to remind the theologians how little help formal religion has been to us in our attempts to understand the problem of abnormality. Only a little while ago the theologians were telling us that men and women go mad because they become possessed of devils; and even more recently they were agitating their congregations to persecute as "witches" poor women whom we now know were merely neurotic, eccentric, or perhaps merely more honest than most people. The saints, on the other hand, were supposed to be individuals who had achieved a particularly close communion with God; but if I am any judge of the situation, a lot of them were just as crazy as the people who were said to be witches or possessed of devils. Psychoanalyst: I don't believe what has just been said is quite fair to the theologians. Granted that there is some justification in the criticism of religion on this score, the fact remains that through the ages it has been the theologians, more than any other group, who have been concerned with the problem of anxiety and neurosis. I think it may interest this group to know that although Freud was not a man who was particularly friendly to formal religion, yet he clearly saw that the medieval religious conception of neurosis was actually not so very different from the conception which he urged. In a paper entitled "A Neurosis of Demoniacal Possession in the Seventeenth Century," Freud (15, pp. 436-37) makes the following remarks :

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Despite the somatic ideology of the era of "exact" science, the demonological theory of those dark ages has in the long run justified itself. Cases of demoniacal possession correspond to the neuroses of the present day; in order to understand these latter, we have once more had recourse to the conception of psychic forces. What in those days were thought to be evil spirits, to us are base and evil wishes, the derivatives of impulses which have been rejected and repressed. In one respect only do we not subscribe to the explanation of these phenomena current in medieval times; we have abandoned the projection of them into the outer world, attributing their origin instead to the inner life of the patient in whom they manifest themselves.5

Chairman: There are several members of our group who have not yet spoken this evening. I wonder if I may call upon some of these gentlemen. I would personally be much interested in hearing, for example, what the biologists have to say about our problems. Biologist: We biologists seem to have two related yet by no means identical conceptions of normality. King (21), writing in the Yale Journal of Biological Medicine, has recently suggested (though the underlying notion can easily be traced back to the Greeks) that the term "normal" should be used in those instances in which functions are in accord with the design or pattern of the reacting structure and that this usage should be maintained without reference to whether these instances are or are not statistically common. Thus he proposes a "pattern norm" rather than a "pattern mean." Here the emphasis is obviously upon an organism's (or machine's) functioning as it is supposed to, according to its design. Or, to put the matter a little differently, one can say that normality is a question of efficiency. The other notion of normality which one is likely to encounter in biology is that of survival. Some biologists say that whatever contributes to survival is normal and that whatever works against it is abnormal. Following Darwin, we often use the term adaptive to describe behavior which is conducive to survival; and I notice that psychologists often also use this term, although I cannot be sure whether it is with precisely the same meaning. Now that I think of it, there is still another notion which one commonly encounters in biological thinking—or perhaps I should say it is merely a way of making at one and the same time both of the points I have just mentioned. I refer here to the concept of normality as equilibrium or balance. Cannon's ( 5 ) theory of homeostasis is a good example of balance at the physiological level. For a more general and 5 Quoted with permission of the Hogarth Press, Ltd., publishers of S. Freud's Collected papers, Vol. IV (1934).

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a somewhat philosophical standpoint, Raup (35) has written about much the same idea under the label of complacency. I am not able to judge the relevance of these conceptions of normality for our present discussion, but I note that those who are most concerned with the problem of personal or psychological normality often use the term "balance," as, for example, when they speak of a person being "well balanced" or "off his balance." Physician: I think the biologists give us some good leads, and I would like to push the same line of reasoning a little further by pointing out that the problem of personal normality is really a question of health. This point of view is tacitly recognized by the common use of the term "mental diseases." And it seems to me that the concepts of normality that hold in biology and medicine for the body are equally valid in the field of psychiatry. Lawyer: I have no technical training in psychology or psychiatry, but my professional practice brings me into contact with a lot of pretty basic human problems and attitudes; and I want to say that for all the efforts of the medical profession to get personal abnormality looked upon benevolently as mere illness, I don't think that these efforts have succeeded or are likely to. Most people are still inclined to look upon madness (save where it has a clearly organic basis, and to some extent even then) as a moral failure, not as an accident or misfortune, such as catching mumps, which "might happen to anybody." Physician: May I remind the preceding speaker that shame is likely to accompany many human afflictions other than those of mental disorder. Take, for example, leprosy or tuberculosis, to say nothing of the venereal diseases. Biologist: Let me try to restate what I was saying a moment ago. I said that biologists—and probably most physicians also—are inclined to say that an organism or machine is functioning normally if it is doing what it is supposed to do, working in the way it was made to work. In other words, one can say that behavior is normal if it's natural. It would seem, therefore,— Anthropologist: The simplicity of such a formulation is certainly attractive, but I must point out its unsoundness as far as our present problem is concerned. Kroeber (23), Murdock (29 ), Opler (31,32), and others have shown that one of man's most distinctive characteristics is that he solves problems by means of culture rather than by means of organic specialization. Thus, for example, the only infrahuman organisms that can fly are ones which have, over millions of years, evolved wings; whereas man, through knowledge, skills, and inventiveness, has been able to make a machine in which to fly, with-

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out any change in himself save that subtle type of neural change which we call learning. Now the import of what I have just said is this. It may be possible to use the structure of lower animals as at least a partial basis for determining what kind of behavior or functioning is "normal" for them; but this criterion breaks down at the human level. It is true that the nature of man's body puts certain limitations on what he can and cannot do; but a part of man's body, namely his nervous system, is so highly plastic that it gives him a phenomenal range of behavior potentialities. To put the matter somewhat paradoxically, but nonetheless truly, we may say that the human nervous system is specialized in nonspecialization. Save in terms of almost meaninglessly broad limits, it is idle to try to define what is humanly normal on the basis of structure. If "normality" has any meaning as applied to behavior at the human level, it is in terms of human culture, not anatomy. Chairman: That line of argument strikes me as a telling one; and I predict that we will find it useful in our further deliberations. However, I am sure there are probably a number of equally fundamental notions which have not yet been brought out. Although our psychoanalyst has already briefly spoken, there is undoubtedly much more that he, for example, could tell us about the problem of normality. Psychoanalyst: Well, I believe there are at least two things which I, as a representative of the analytic group, ought to mention. You will certainly not be surprised if the first thing I suggest is the role of the "unconscious" in the determination of abnormality. As a colleague of mine recently put the matter, if a person's motives are mainly conscious he is normal, but if they are mainly unconscious he is abnormal. This, of course, is just another way of saying that, although some degree of repression may be inescapable in civilized existence, the too extensive occurrence of repression is sure to cause trouble sooner or later. By the same token, therapy consists of the release of repressed motives into conscious awareness and is accompanied by what we call "insight." My second point is this. One of the most distinctive features of the neurotic individual is what clinicians almost universally term "disproportionality of affect." Our analytic theory of this phenomenon, in its simplest form, is that the individual learns as a child to be afraid of certain things which, in childhood, it is entirely appropriate that he should fear, as, for example, the power and authority of his father. But if an individual continues to have these same fears as an adult when his life circumstances are very different, then we speak of neurosis. In this connection we also use the expression "overdetermina-

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tion" of behavior, but if I attempted to explain this concept I would not add anything fundamentally new to what I have already said. Psychologist: As some of you probably know, a lot of psychologists have been interested in trying to "integrate" psychoanalytic concepts with some of our commonly accepted psychological principles. In connection with the last point, for example, many of us would say that it is a question of the individual's having generalised certain attitudes and habits from childhood into adult life, without having been able to make the requisite discrimination, i.e., without seeing that the situation is now different (19). Psychiatrist: I don't follow a lot of this new thinking—I am a practical man and have to do things, not just speculate about them. I am inclined to agree with my colleagues, Cobb (6), Darrah (7), Hacker (18), Jones (20), and others when they maintain that, in theory, there just isn't such a thing as a normal man. And for similar reasons there is no clear-cut way in which one can differentiate a so-called abnormal man from a so-called normal one. I have been connected with mental hospitals for nearly thirty years, and for every species of craziness you can find in such an institution, I'll find the same one or another in people who are at large. The long and the short of it, as far as I am concerned, is that "abnormal" people are simply people who manage their relationships with other persons in such a way that these other persons are highly motivated to "get them out of the way," whereas "normal" people do a little better. Neurologist: There is a study,6 conducted at the Wakefield Mental Hospital, which suggests that the normal brain differs from the abnormal brain in the actual number of functioning cells in the two areas of the cortex, namely, the infragranular layer and the supragranular layer. The more nearly normal the brain, the wider the supragranular layer and the narrower the infragranular layer. I am not sure how good the controls were in this study, and I mention it, not because I think it is definitive, but merely as a means of indicating how nearly inexhaustible are the criteria according to which one can approach this problem of normality. I wonder, in fact, if it isn't desirable to let each professional group approach it from whatever standpoint is best suited to the needs of that group, and if it isn't something of a waste of time to try to agree upon any more general criteria. Biologist: I don't at all feel that our discussion has been a waste of time this evening, but I am wondering if we will get much further than 6 The details of these studies, conducted in England by Drs. G. A. Watson and J. Shaw Bolton, are discussed in R. J. A. Berry and R. G. Gordon, The mental defective (New York: Whittlesey House, 1931).

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we already have if we continue to use the same method of approach. As a biologist I tend to be interested in generalizations and principles that are broader than individuals and, at the human level, also broader than particular societies and cultures. Our neurologist has just suggested one way in which we might get a universal basis for talking about abnormality, and I wonder if there aren't other possibilities. Chairman: One hears a good deal these days about "learning theory." I wonder if that would offer any hope of a solution. Psychologist: One hesitates to push his own specialty too hard in a group like this, but I think that learning theory does indeed offer some important possibilities in this connection. I can't say that I, personally, have ever attempted to think through the problem of personal normality in terms of the principles of learning; but I believe it would be well worth trying to do so. However, I am afraid the task would be rather complicated. Anthropologist: I want to enter a vigorous demur concerning this suggestion that we may be able to solve the problem of normality and abnormality in terms of universals. It is perfectly evident to me that normality and abnormality vary enormously from one culture to another, and in the same culture through time; and I, for one, am afraid of any attempt to set up criteria or standards for all mankind. This is a pluralistic world, and different peoples differ. Who is to say that one is right and the other wrong, the one normal and the other abnormal? Remember that the Nazis thought they had a universal set of human standards. And I want to point out that in their zeal as missionaries, members of our own society have done some things which are just about as deplorable. W e have gone into simpler societies which were functioning very well and started a campaign to undermine the native culture. All too often we have succeeded, but how often— and here is the tragedy—have we been willing to accept our "converts" into our own society and way of life on an equal footing ? Psychologist: I believe you have missed the point of my last suggestion. In general terms, I agree with all you have just said, and there is nothing in my remarks which is in the least contradictory. I fully agree that, as a result of their particular socialization, human beings often learn quite different things; but, so far as we know, the basic principles governing human learning are the same the world over. W e differ, in other words, in what we learn but not in how we learn. Biologist: That sounds right to me. You fellows in the social sciences don't get down to biological bedrock as often as I think you ought to. But I wonder if there isn't another way, in addition to that

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offered by learning theory, of tackling this problem. I cannot claim to know very much about psychoanalytic theory, but I am favorably impressed by it in terms of the little I do know and am wondering if it does not give us some leads for getting out of our present difficulty. Chairman: I notice a number of approving nods in response to what the last speaker has just said, and if there is no objection I will take it as the will of the group that at the next meeting, a week from tonight, we shall renew our attack upon the concept of normality but from the more systematic and restricted standpoints of learning theory and psychoanalytic theory. Second Group Discussion Chairman: From our discussion of last week it became evident how complicated and many-sided is the problem of personal normality. I shall not attempt to summarize the many different points of view which were expressed at that time, except to say that for every way of looking at the problem which was put forward, one or more seemingly valid objections could be advanced. The only prospect of reaching any degree of uniformity in our thinking which emerged was that of identifying certain universal attributes of human beings and trying to resolve our problem in terms of them. It was agreed, you will recall, that at our meeting this evening we should explore first the psychology of learning and then see what psychoanalytic theory might have to offer in this connection. I wonder if we may therefore ask our psychologist to start the discussion. Psychologist: I find myself somewhat embarrassed on two counts. First of all I must confess, before you point it out to me, that there is by no means universal agreement among psychologists as to what the universal principles of learning are. You will therefore have to forgive me if I am slightly arbitrary and simply present what I personally believe to be the best-established concepts and principles in this field. My second reason for being a little uncomfortable about my role this evening is that in order to get across enough information for it to be of any real help to us, I shall have to speak at somewhat greater length than is customary in our group. To begin with a general statement about the history of learning theory, one can say that there have been three great streams of thought in this connection: associationism, hedonism, and rationalism. These terms will immediately be familiar and meaningful to you, in a general way, so I shall proceed to speak about the contemporary, technical state of each of these three types of theory.

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Modern thinking and research concerning associationism tends to be couched in the jargon of "conditioning." This, you will recall, is a method of investigation which the Russian physiologist, I. P. Pavlov, (33), developed for investigating what he called the "physiology of the highest nervous centers." In essence, it involves presenting to the subject (Pavlov worked mainly with dogs) some initially neutral stimulus, such as a buzzer or a light, which is then followed by a stimulus which can be relied upon (either reflexively or through prior learning) to produce some specified response. For example, in much of the work done in Pavlov's laboratory, the signal, or "conditioned stimulus," was presented and then shortly followed by food. The food would prompt the subject (if hungry) to respond by salivating and eating. The result of this procedure was that, after a few paired presentations of signal and food, the subject would begin to salivate to the signal alone. This kind of learning has sometimes been called "stimulus substitution," and it is easy to see the aptness of this expression. The conditioned stimulus becomes, in a very literal sense, a substitute for the unconditioned stimulus in that it produces much the same reaction as the unconditioned stimulus. Or, to put the matter a little differently, the subject acts as if the CS were the UnCS. We say that the CS (buzzer) has come to mean, or stand for, the UnCS (food). Although associative learning of this kind has certainly been known for a very long time, it was Pavlov who introduced a method for its precise, quantitative investigation; and so great was the enthusiasm with which this method was received by researchers the world over that, in their enthusiasm, they seem to have overextended the method. They began to experiment, not only with the salivary and other glandular responses, but also with skeletal responses. They found, for example, that if one sounds a buzzer and then shocks a dog on the forepaw in such a way as to elicit a flexion of the leg, after a few paired presentations of this kind the dog will flex the leg to the buzzer alone. Here, ostensibly, was another example of conditioning. But this inference has introduced no end of confusion. We now know that the thing the dog learns first in a situation of this kind is to be afraid when the buzzer sounds; this is certainly conditioning. But we also know, or at least strongly suspect, that paw-lifting (and many other things an animal may do in a situation of this kind) occurs, not directly in response to the conditioned stimulus, but rather as a reaction to the fear which the CS produces. On the basis of a great deal of work which I can't begin to review here, it is becoming increasingly clear that conditioned-response learn-

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ing, properly speaking, is always restricted to responses of the visceral and vascular tissues, which mediate the various so-called "emotions" and are produced by the autonomic nervous system. Skeletal responses, on the other hand, are learned on another basis. This now leads us to a discussion of the second great principle of learning. Hedonism, as you all know, is the theory that, as Jeremy Bentham put it, "we are propelled by pleasure and repelled by pain" (4). Contemporary thinkers who may be said to follow in this stream of thought put the matter a little differently. They say that living organisms experience discomforts or "drives," are thrown into activity by these drives, and tend to remain active until some response is made which terminates the drive state or motivation. We know incontrovertibly that a response which "solves a problem" tends to get reinforced or learned, in the sense that it will be more likely and quicker to recur when the problem which it has previously solved recurs. You will, of course, be likely to think of E. L. Thorndike as the person who has worked most extensively with learning of this kind and who has popularized the term Law of Effect to characterize it (38). But there are literally hundreds of other investigators who also know that this type of learning is a genuine phenomenon and who, in a general way at least, subscribe to Thorndike's views. But here again there have been some oversights which have caused a great deal of confusion. For example, most demonstrations of the Law of Effect have been carried out with subjects (mainly infrahuman animals) which have been motivated by primary drives, e.g., hunger, thirst, pain, or fatigue. What has been commonly overlooked is the fact that the Law of Effect is also valid in the area of emotional problem solving. We now know that a living organism will learn a given response or type of behavior quite as readily from the drive of fear as from that of hunger. In fact, we may even say that at the human level most of our problem solving is directed at emotional problems or secondary drives, rather than at the primary drives, which we manage to keep pretty well satiated most of the time. There are other sources of misunderstanding which might be discussed, but you will find these rather fully dealt with in the technical literature (28), and we need not consider them here. In short, then, we see that research with animals has shown that there are two great learning processes, conditioning and problem solving; and there is abundant evidence that these processes occur in human beings no less than in the simpler organisms. But there are many writers, especially those with a more philosophical turn of mind, who have never been content with these two theories as a sufficient

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basis for explaining human behavior, either at its best or at its worst. These persons have insisted that there is a factor or faculty of rationality which must be prominently considered, and they have maintained that neither conditioning nor problem solving, as such, accounts for rationality. Some of the persons who are the loudest in their protestations on this score are persons who are simply unaware of what the principles of conditioning and problem solving really imply, and they don't wish to sully—or, as I should prefer to say—discipline their minds by becoming fully informed on these scores. However, I should like at once to say that I admit that there is some justification in these reservations concerning learning theory. Those of us who are technically engaged in the study of learning have not, I think, devoted nearly as much time and thought as we should have to the problems and functioning of the "total personality," if I may use that hackneyed expression. I admit that there is a good deal more to human experience than our theories seem to imply, but I believe that we shall ultimately come to a real understanding of the quintessence of human personality only if we build slowly and securely upon basic principles which can be established by the tested methods of scientific inquiry. If we continue trying to understand man in a global, molar manner, I can only foresee confusion being compounded with confusion ( 2 6 ) . Let me now try to draw together the implications of my remarks for our discussion of the problem of personal normality and abnormality. I should like to suggest, first of all, that the normality-abnormality problem—or, if you prefer, the problem of rationality and irrationality —stems from a deep-seated conflict between the two forms of learning which I have just discussed, namely, problem solving and conditioning. Note that problem solving predisposes the individual to behavior which, by definition, solves his problems, makes him comfortable, gives him satisfaction and pleasure, whereas conditioning works in exactly the reverse manner. Through problem solving behavior, the individual lessens his drives, whereas conditioning brings new drives into existence or intensifies old ones. It is through conditioning that fears, resentments, appetites, and other emotions are acquired; and if they are anything, they are "problems," psychologically speaking. Psychoanalyst: There is something in what you are saying which is reminiscent of the distinction which Freud (14) made between the "pleasure principle" and the "reality principle." I wonder if you would agree that there is a similarity. Psychologist: Yes, indeed. I think my main point is even recognized by the man in the street when he speaks of a neurotic or psy-

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chotic as "self-centered" and "unable to face reality." In fact, I was surprised that in the course of our discussion last week no one made any reference to the ability to "face reality" as an important, perhaps the most important, attribute of the normal, mature individual. Perhaps the difficulty was that we didn't know quite how to put this notion precisely. Here I think our survey of learning theory may be helpful. The "ability to face reality" is, I believe, the ability or willingness to expose oneself to such conditioning as is essential (a) to the physical survival of the individual and (b) to his social and ethical development. This ability or willingness has to be learned, at least in the case of human beings; and it has to be learned on the basis of the Law of Effect. And here is where the paradox lies and the trouble begins. In order for a human being to be regarded as "normal" in any society, he must have learned that the best way to safeguard his comfort and well-being in the long run is to "face reality," i.e., to expose himself on occasion to present hardship or suffering as the surest way of insuring future survival and satisfaction. To the extent that lower animals may be said to behave in this farsighted manner, they do so on a predominantly instinctual basis. But man, having been largely freed from the rigidity and fixity of instincts, has to learn "wisdom and virtue," either through education or through experience. In either case, it is hard to reach the point of being able to give up a sure and immediate gratification for a remote and perhaps uncertain one. An earlier speaker referred to abnormality as "moral failure" and pointed to the social opprobrium that abnormality so commonly causes. If he is willing to define the "moral problem" as I have just done, I think I would agree with him entirely; but we ought to be sure we see all the implications which such a view has. It repudiates the concept of normality as mere averageness and makes it a matter of an ideal— full manhood and womanhood are difficult of achievement in any and every society, and the "abnormal" person is the one who hasn't "made the grade." Philosopher: You would surely be surprised if I, as a philosopher, did not agree with what our psychologist has just said. I am not sure what his fellow psychologists will have to say about his analysis, but it will find good precedent in the thinking of many philosophers. For example, some years ago R. B. Perry published an important book, called General Theory of Value (34) in which he suggested that an action or object may be valuable or efficient in any of three frames of reference. An action is valuable if it helps the individual to survive,

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i.e., if it is adaptive. An action is valuable if it helps the individual to experience pleasure, to become more comfortable, i.e., if it is adjustive. And, finally, an action is valuable if it helps the individual to reconcile, harmonize, unify the competing, conflicting demands which are made of him, i.e., if it is integrative. I was reminded of these three frames of reference, these three value-systems, by the remarks of the preceding speaker concerning what he referred to as associationism, hedonism, and rationalism. Although the parallelism is not perfect, yet it is noteworthy that in associative learning the emphasis is upon survival or adaptation; in hedonism it is upon comfort, adjustment; and in integration it is upon the highest kind of mental activity or rationality. But what does all this have to do with the problem of normality? The answer, I think, is implicit in what our psychologist has already said. The discussion last week made it evident that the problem of normality cannot be settled statistically but must rather involve the concept of efficiency, a goal, an ideal. But last week we did not come to grips with the question: Efficiency for what? What I have just been saying seems to me to provide a possible answer. There are three great frames of reference in which a given action may be said to be efficient or inefficient, or, if you will, normal, or abnormal; one can even say, good or evil. In the first of those frames of reference an action is efficient if it promotes the survival of the individual (and, we may add, the perpetuation of his species). In the second, an action is efficient if it gives pleasure, provides comfort. And in the third frame of reference, an action is efficient if it is ethical or integrative; and by "integration" I mean the process whereby conflicts, of both a personal and interpersonal nature, are reconciled and the basis laid for individual happiness and social solidarity. One of the principal reasons, I suspect, why our discussion last week appeared to be getting nowhere was that we were not clearly differentiating among these three frames of reference, and it was for this reason that whenever one person proposed a definition of normality or "efficiency" in terms of one frame of reference, someone else, by jumping to another frame of reference, could always find what seemed like a compelling objection. Sociologist: It seems to me that there may be a good deal in what you say, but, as philosophers are wont to do, you've got the discussion up on a high plane of abstraction. Can you make what you have just been saying more concrete and specific ? Philosopher: I am not sure that I can, but I will try. Let me first say, however, that I don't feel that I need be apologetic for the philosopher's tendency to translate problems into rather abstract terms: this

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is the only way in which we sometimes succeed in solving what otherwise seem to be hopeless dilemmas. But let us try, now, to do as our sociologist has just suggested. I shall have to get out of my field of professional competence, but if I err some of you will be able to correct me. From my rather cursory familiarity with psychological and clinical literature, I gather that it is commonly assumed that abnormality or psychopathology always involves conflict, but that conflict is not necessarily pathological. In other words, there can be normal conflict as well as abnormal conflict. What is the deciding criterion ? I suppose there can be and sometimes is conflict in human beings between the mechanisms which tend to insure man's physical survival and the mechanisms which dispose him to act in such a way as to make himself comfortable. In a book which I happened to be browsing in recently (25), I noticed that the point was made that in most instances actions which are adjustive are also adaptive, and that only in relatively rare instances is there any discrepancy. The case of a person who ate food that tasted all right and satisfied hunger but which was poisonous and killed the eater or made him very ill was given as an instance of this. But I doubt that it is conflicts of this kind that lay the basis for what we call abnormality. I believe, rather, that it is only when we get to adjustment and integration that the plot thickens and the broth begins to boil, if I may mix my metaphors. Man's quest for comfort has taught him that in many situations the best way to be comfortable, in the long run, is to forego the possibility of comfort or pleasure at the moment. But this has always been a hard thing for man to do. It is, in a word, the moral quest, the ethical struggle—a quest, a struggle which man has never been able either to abandon or to master. And it is in this area that I, like the psychologist, think we shall find the cue to neurosis and to the symptomatic behavior which we term "abnormal." This thought has been neatly phrased in a manner quite devoid of the philosopher's ponderous touch, in an extraordinary book entitled, Man: An Autobiography, which appeared in 1946 (37). In it the author remarks: Some other qualities of the individual I would infer to be very old because I have been trying for centuries to get rid of them, and yet I have them just as much as ever, if not more—pride, vanity, envy, hypocrisy, gluttony, and indifference to the suffering of others. On the contrary, there are some qualities which I have always been trying to develop and which I never get the hang of: for instance, self-restraint, foresight, and placidity. I am simply not in the class of the beaver or

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elephant or honeybee. Even the cat fills me with admiration and wonder at her patience before a mouse hole. I am more nearly of the grasshopper's persuasion (37, p. 61 ). 7

Now I am really little more than a layman when it comes to the technical aspects of psychology and psychiatry, but I have a strong conviction that, philosophically, there is something seriously wrong with the modern conception of neurosis and its treatment. In keeping with the three frames of reference which I described earlier, we seem to find people questing for happiness in three different ways: through long life and good health (adaptation, survival) ; through the pursuit of pleasure (adjustment, tension-reduction) ; and by trying to become mature, adequate persons (integration). Human history seems to show that persons who spend much of their time thinking about either health or pleasure usually end up with little of either. Most men—at least most men whom we are likely to look upon as having achieved some semblance of wisdom—seem to have concluded that "pride of character" is a much sounder guide to happiness and personal normality. This is a point of view which seems to have been largely lost sight of in recent decades. I wonder if our psychoanalyst can carry this line of thought any further ? Biologist: I, too, should like to hear what the analysts have to say in this connection; but may I interrupt with only one question ? May I ask our philosopher if we are to conclude that, since the normalityabnormality problem, in his judgment, hinges upon what he has called the "ethical struggle," and since this is a struggle which individuals in every society have to face, we thus approach a universal conception of normality and abnormality and escape from some of the difficulties into which we got last week ? Philosopher: That is certainly in line with my own thinking. And I should like to add that, if my more or less intuitive judgment is any guide in the matter, the solution to the problem of neurosis lies in the direction of conquest of the moral problem, not in the abandonment of it, as I believe is at least implicit in the minds of some of our modern psychotherapists. Chairman: These last remarks seem to me to make it more incumbent than ever upon our psychoanalyst to speak. You will recall, moreover, that last week we planned, in any event, to spend a portion of this evening discussing his specialty. Psychoanalyst: I ought to say, first of all, that Freud often insisted that psychoanalysis was a science and that it did not lead to any par7 Quoted with permission of Random House, Inc., publisher of G. R. Stewart's Man: an autobiography (1946).

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ticular philosophy of life (13), but at the same time his writings often had an unmistakable philosophical tinge (12); and I confess some sympathy with the point of view which has just been expressed, to the effect that you can't have an adequate theory of personality or an efficient technique of therapy unless you are willing to come to grips with the ethical problem (27). I will leave it to you to judge how well psychoanalytic theory meets these needs and will confine myself, at least for the time being, to a purely expository role. Last week I gave two criteria which analysts believe to be important in the identification of neurosis. This evening I don't propose to say anything very different, but I should like to put it in a different way. At an early point in his career, Freud saw that anxiety was the crucial problem in neurosis, and he succeeded in making the whole world realize that it is futile to treat a so-called abnormal person solely on the basis of his symptoms. Consequently Freud thought and wrote a great deal about the problem of anxiety, and I shall try briefly to indicate his major contributions in this connection. Freud's first theory of anxiety was published in a series of papers (9, 10, 11) which appeared between 1892 and 1896. The essence of this theory was that when there is sexual frustration and repression in the life of the individual, sexual tension, or "libido," builds up to such an extent that it erupts, as it were, into the consciousness of the individual but is experienced, not as lust or passion, but as anxiety. Freud said, in fact, that it was as if the sexual impulses were thus "transformed" into anxiety. It follows as a corollary of this theory that psychotherapy should attempt to help the individual accept his own sexual impulses as a part of himself and to find satisfactory outlets for them. Freud's second theory of anxiety, which came to complete expression many years later (13, 16), was in some respects much the same as the first one, although in some ways notably different. Freud started with the assumption that the individual, usually a small child, has certain impulses, very commonly of either a sexual or hostile character. These cause him to engage in exploratory behavior—I presume a psychologist might call it trial-and-error or problem-solving behavior—as a result of which a form of gratification is found, a "fixation" is established, a "habit" formed. But this habit, or adjustment, is likely to be socially disapproved; and representatives of the child's society, usually in the form of his parents, "crack down" on him, punish him. The result is that the child, again in the words of our psychologist, becomes conditioned, i.e., when the child starts to do the forbidden act, the fear

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of punishment is aroused. This fear is likely to be stronger than the original impulse, with the result that when the fear is aroused the child is likely to become more intent upon reducing the fear than upon gratifying the original impulse. Obviously, the most direct way to reduce the fear is for the child to inhibit the contemplated action, i.e., resist the "temptation," as we are likely to say. Thus far we have only a theory which accounts for the inhibition of an overt action, a theory of what Freud was likely to refer to as "suppression." In this situation the individual is still aware of the original impulse, but he decides not to act upon it, not to gratify it, at least not in the way which has previously got him into trouble. But suppose, now, that the child tries other ways of satisfying his needs, and that every time he seems to find a solution, that, too, gets him into difficulty with his elders. Eventually he may decide that it is not a question of some ways of solving his problem being wrong and others being all right. It is rather that any gratification whatever of certain impulses is wrong, and from this it is but a short step to the conclusion that the impulse itself is "wrong." I don't mean to say that the child necessarily reasons it all out in just this way. Perhaps the more accurate way to put it is to say that eventually the child gets to the point where he is afraid, not simply when he contemplates a given action, but whenever he even experiences the underlying impulse or need. At this point, says Freud, something momentous and, in a way, monstrous often happens: as a means of escaping from the fear that the impulse always arouses, the child repudiates the impulse, represses it, denies it access to consciousness. This strategy, which may be carried through with an admixture of conscious and unconscious elements, often provides a temporary, sometimes a surprisingly durable, state of peace within the individual. Freud believed, however, that a repression is always maintained at a certain cost to the individual, and that in times of crises it is likely to give way altogether. Whenever the repression is weakened and there is a danger that it will be abrogated, whenever there is danger of what Freud termed "a return of the repressed," then one experiences anxiety; and it is anxiety, according to Freud, which starts human beings to behaving in those self-defeating, vicious circles that we call neurosis or abnormality. Neurologist: I think I follow what you have said, but I seem to detect in it the same ambiguity that I have always felt inherent in Freud's writings. In his first theory he said that the repression comes first and the fear, anxiety, or neurosis comes afterward. In his second theory he seems to be saying that the fear has to be there first; then

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repression occurs, doesn't work very well, and the fear is experienced again. This all seems somewhat out of focus to me, but I can't say exactly why. Psychoanalyst: 1 can well see why you should be a bit confused here. Unfortunately, Freud was not always entirely consistent in his use of the terms "fear" and "anxiety," and many of his followers have been even less so. The first theory of anxiety was weak in that it had no dynamic explanation as to why the frustration and repression occur in the first place. The second theory posits fear as the cause of the repression, and up to this point we do not speak of anxiety. It is only after repression has occurred and the wish, or impulse, has been "lost sight of" that there is the possibility of anxiety. Fear always has an object; we are afraid of something. Anxiety, by contrast, is always objectless; we are never anxious of—we are just anxious. And it is one of the major objectives of therapy to convert anxiety into fear. This can be done—in fact many analysts believe that it can only be done—by the technique which Freud worked out. The individual finds what it is that he is really afraid of when he is anxious; he has "insight," as we say; and he then either sees that his fear is no longer valid, or he finds ways of achieving his adult purposes by means which do not arouse the same social disapproval to which his more infantile, immature behavior exposed him. Chairman:. I feel that this exposition must bring us very close to an explicit, and perhaps universal, theory of normality and abnormality ; but I think it would be useful if the speaker could guide our thinking a little further along these lines. Psychoanalyst: To be perfectly candid with you, I am not sure whether I can or not. It is certainly true that Freud has given us a lucid and explicit theory of anxiety, and on the basis of it one might say simply that the most normal person is the one who has the least anxiety. But I confess that I feel confused and uncomfortable when this criterion is suggested. Although we analysts have worked much more with so-called neurotics than we have with criminals or psychotic individuals, we can be pretty certain that there are a lot of criminals—• "pure criminals" I like to call them (to distinguish them from the "neurotic criminals")—who probably have no more anxiety, perhaps even less, than do so-called normal persons. Does this, then, make the criminal "normal" too? We cannot, of course, be sure, but it also looks as if there were at least some types of psychotic individuals—I am thinking particularly of the simple or "pure" schizophrenias—who are remarkably free from anxiety. But surely this does not make them "normal." Yet the fact seems to remain that, as Freud said, anxiety

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is "the fundamental phenomenon and the central problem of neurosis" (16, p. 111). If anyone can throw light upon this enigma, I hope he will do so. Layman: In this group I feel it behooves me to keep still most of the time. The only thing this leaves me to do is to listen, and that I try to do well. If I have been as careful a listener to the discussion this time and last as I have tried to be, I have heard some things that the rest of you, with your intense professional specializations and preoccupations, may have missed; and I am going to try to put these things together in such a way as may give us "closure," as I believe the Gestalt psychologists are fond of saying. Earlier this evening our psychologist pointed out that there is a conflict between the tendencies on the part of living organisms, including man, to make problems for themselves (through conditioning) and to try to rid themselves of problems (through problem-solving). He suggested that normality might consist of a kind of balance or equilibrium between these two tendencies, leading to something which we may call rationality. Our philosopher has eloquently indicated that he sees the problem as a struggle between the quest for pleasure (or problem-solving in the immediate, headlong manner of animals) and the ethical enterprise (which may be thought of as problem-solving through time). Our psychoanalyst has said, by implication at least, much the same thing: neurotic conflict arises because of a clash between the individual's animal needs and propensities and the taboos and prohibitions of organized society. And, again by implication, he has said that therapy, or normality, is achieved when a person who is overly inhibited becomes less so, strikes a kind of balance or equilibrium between restraint and gratification, such as our psychologist seems to have had in mind. I should like to point out what I believe to be the basic misconception in psychoanalytic theory and the one which, if corrected, will do more than anything else to bring all of our views into relatively good agreement. It is a cardinal assumption of the analysts that neurotic individuals are persons in whom the socialization process has been carried too far, with the result that the individual makes more renunciations, is less demanding, and is "better" than there is any need for him to be. The analysts say that the "superego is too severe," and they make it the aim of therapy to lessen its tyranny. According to this conception, the normal person may be thought of as occupying a kind of middle ground, with the criminal on his left, as an undersocialized person, and the neurotic on his right, as an over-

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socialized person. Therapy thus consists of trying- to get the neurotic to move over a little in the direction of the criminal but to stop short of going all the way, on the middle ground of normality. If I have properly caught the overtones of much that other members of our group have been saying, it is this : that the neurotic is not an overly socialized, "supernormal" individual but is instead one who falls, in terms of his character development, somewhere between the criminal and the normal person. I believe that this is what our philosopher had in mind when he said that man was so far committed to the moral enterprise that his only real prospect for happiness is to pursue it, rather than to turn away from it in the direction of criminality. And if this general point of view is correct, then psychotherapy would consist, not in trying to make a neurotic normal by urging him in the direction of criminality, but away from it. One might say, I should think, that the neurotic is a person who has "got stuck" in between, one who has the potentiality (much more than the criminal can be said to have) to become normal, but who needs a little extra help to "get over the hump." I know the hour is late and I can imagine that many of you who are technically better qualified to speak along these lines than I am probably have a number of objections which you would like to make, but there are just two more things I would like to say and then I will stop. They are merely footnotes to what I have already said. I do a little reading now and then in a great many different fields, and I gather in this way that psychiatrists have a kind of "wastebasket" category into which they lump persons who are neither clearly neurotic nor clearly criminal, yet who are certainly not normal. They call these persons "psychopaths," and it is acknowledged that they have some of the characteristics both of the criminal and of the neurotic; yet this mixture does not produce a normal person, as the psychoanalytic theory of personality types would lead us to expect. Note how readily this paradox disappears if you put the neurotic in between the normal individual and the criminal: since you then have the neurotic and the criminal side by side, so to say, you can naturally and easily put the psychopath in between them! But what about the psychotic individual ? Here I feel very tentative and deferential indeed; but if my fragmentary reading is any guide, I should suppose that the psychotic individual is merely a neurotic who manages his anxieties in a particular way, i.e., by retreat from and denial of reality. Since it is, in many instances, such a stable style of life, one might say that, from one point of view, it is the most "successful"

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type of neurosis. But this is something I shall certainly have to leave to the ultimate judgment of more competent individuals than myself. The final thing I want to point out is that if psychiatrists, psychoanalysts, clinical psychologists, and others who purport to do psychotherapy could take the point of view concerning neurosis which I have tried to suggest, I believe it would accomplish two great things : (a) it would do much to remove the intuitive feeling on the part of many laymen that "most psychiatrists are just as crazy as their patients," and (b) it would do much to bring together the so-called modern scientific theories of human personality and the traditional philosophical and religious conceptions of man. Philosophers, theologians, and laymen alike do not, in my judgment, look with distrust upon modern clinicians because they take a naturalistic as opposed to a supernaturalistic view of human nature and its vagaries, but because clinicians tend to take, at best, an unmoral view of man and, in some instances at least, a view which one is perhaps even justified in calling antimoral. Chairman: I am sure we are all grateful to the last speaker for his synthesis of the various lines of thought and argument which our discussions have developed. Last week, and again this evening, I have taken rather full notes on what has been said, with a view to presenting an over-all summary. But I am afraid that such a summary would be unduly long or, if I made it reasonably concise, would be so abstract as to have little meaning. I should, however, like to restate what seems to me to be the fundamental notion at which we have arrived. W e have reviewed a great many different ways in which the term "normality" is often used—in statistics, sociology, education, medicine, psychology, psychoanalysis, philosophy, theology, and others—but we find that no one of these usages gives us just the conception we are seeking. W e find, moreover, that almost any specific action or personal characteristic which is regarded as "abnormal" in one society has been or is regarded as "normal" in another society, all of which raises the specter of "cultural relativity." But we seem to have hit upon a way of laying this ghost. We find that, regardless of the way in which the details of approved action and attitude differ from one society to another, there is one thing common to life in all societies. Every human society is organized and conducted on the basis of certain principles—which are best described as social ethics. These principles have been worked out over a long period of time, with many mistakes and much suffering. Each individual born into a human society is under pressure to adopt the approved ways of that society, and each individual experiences in the

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course of his own development some of the struggles, difficulties, and dilemmas which were involved in the evolution of his society. To the extent that an individual is able in his lifetime to assimilate the historically hard-won wisdom of society and to experience the fruits thereof, he may be said to be normal; to the extent that he fails, he is abnormal. Since this is a struggle in which individuals in every society must engage, we arrive in this way at a conception of normality which is not culture-bound and yet which takes due account of the enormous importance of the culture-assimilation process. This is not to say, however, that slavish conformity is the touchstone of happiness and normality. It seems empirically well established that, by and large, the good men in a society are the conforming and happy men. Only by making one's peace with one's society and "playing the game" does one seem to achieve the kind of freedom and fulfilment that attend the good life. But it is perhaps less a matter of conformity, as such, than of consistency. In most instances consistency and conformity dictate the same course of action; but if, for whatever reason, nonconformity seems imperative, then openness therein and willingness to take the consequences are requisite. When nonconformity and inconsistency—in the sense of duplicity and evasion— are combined, the soil of social alienation is prepared and the seeds of personal abnormality are sown. I assume that we hold this view with an appropriate degree of tentativeness; perhaps some of the members of our group may hardly subscribe to it at all. But when we realize that it represents the coalescence of many of the basic tenets of traditional philosophy and religion and of much that seems soundest in modern social and psychological science, the plausibility of the position is impressive. REFERENCES 1.

ADLER, A.

Problems of neurosis. New York: Cosmopolitan Book Corp., 1930.

2. . Social interest: a challenge to mankind. London: Faber & Faber, 1938. 3. ALLPORT, F. H. Psychology in relation to social and political problems. In P. S. ACHILLES (ed.), Psychology at work. New York: Whittlesey House, 1932. 4. BENTHAM, J. Principles of morals and legislation. Oxford: Clarendon Press, 1879. 5. CANNON, W. B. The wisdom of the body. New York: W. W. Norton & Co., Inc., 1939. 6. COBB, S. Borderlands of psychiatry. Cambridge, Mass.: Harvard University Press, 1943. 7. DARRAH, L. W. The difficulty of being normal. / . nerv. ment. Dis., 1939, 90, 730-39. 8. DEARBORN, W. F. Intelligence tests. Boston: Houghton Mifflin Co., 1928.

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9. FREUD, S. The defence neuro-psychoses (1894). In Collected papers, Vol. I. London: Hogarth Press, Ltd., 1924. 10. . The justification for detaching from neurasthenia a particular syndrome: the anxiety-neurosis (1895). In Collected papers, Vol. I. London: Hogarth Press, Ltd., 1924. 11. . Further remarks on the defence neuro-psychoses (1896). In Collected papers, Vol. I. London: Hogarth Press, Ltd. 1924. 12. . Civilisation and its discontents, London: Hogarth Press, Ltd., 1930. 13. . New introductory lectures on psycho-analysis. New York: W. W. Norton & Co., Inc., 1933. 14. . Formulations regarding the two principles in mental functioning (1911). In Collected papers, Vol. IV. London: Hogarth Press, Ltd., 1934. 15. . A neurosis of demoniacal possession in the seventeenth century (1923). In Collected papers. Vol. IV. London: Hogarth Press, Ltd., 1934. 16. . The problem of anxiety. New York: W. W. Norton & Co., Inc., 1936. 17. FROMM, E. Man for himself: an inquiry into the psychology of ethics. New York: Rinehart & Co., Inc., 1947. 18. HACKER, F. H. The concept of normality and its practical significance. Amer. J. Orthopsychiat., 1945, 15, 47-64. 19. HULL, C. L. Principles of behavior. New York: Appleton-Century-Crofts, Inc., 194320. JONES, E. The concept of a normal mind. Int. J. Psychoanal., 1942, 23, 1-8. 21. KING, C. D. The meaning of normal. Yale J. Biol. Med., 1945, 17, 493-501. 22.

23. 24. 25.

26. 27. 28. 29. 30. 31. 32. 3234. 35. 36. 37. 38.

KLUCKHOHN, C , and KELLY, W. H.

The concept of culture. In R. LINTON

(ed.), The science of man in the world crisis. New York: Columbia University Press, 1945. KROEBER, A. L. The superorganic. Amer. Anthrop., 1917, 19, 163-213. MALLER, J. B. Personality tests. In HUNT, J. McV. (ed.), Personality and the behavior disorders. New York: The Ronald Press Co., 1944. MOWRER, O. H., and KLUCKHOHN, C. Dynamic theory of personality. In HUNT, J. McV. (ed.), Personality and the behavior disorders. New York: The Ronald Press Co., 1944. MOWRER, O. H., and ULLMAN, A. D. Time as a determinant in integrative learning. Psychol. Rev., 1945, 52, 61-90. MOWRER, O. H. The law of effect and ego psychology. Psychol. Rev., 1946, 53, 321-34. . On the dual nature of learning—A reinterpretation of conditioning and problem solving. Harv. educ. Rev., 1947, 17, 102-48. MURDOCH, G. P. The science of culture. Amer. Anthrop., 1932, 34, 200-15. OLSON, W. C. The measurement of nervous habits in normal children. Minneapolis : University of Minnesota Press, 1929. OPLER, M. E. Cultural and organic conceptions in contemporary world history. Amer. Anthrop., 1944, 46, 448-60. . Biosocial basis of thought in the Third Reich. Amer. sociol. Rev. 1945, 10, 776-86. PAVLOV, I. P. Conditioned reflexes. London: Oxford University Press, 1927. PERRY, R. B. General theory of value. New York: Longmans, Green & Co., Inc., 1926. RAUP, R. B. Complacency: the foundation of human behavior. New York: The Macmillan Co., 1925. ROBACK, A. A. The psychology of character with a survey of temperament. New York: Harcourt, Brace & Co., Inc., 1928. STEWART, G. R. Man: an autobiography. New York: Random House, Inc., 1946. THORNDIKE, E. L. Human learning. New York: Appleton-Century-Croftst Inc., 1931.

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39. TIEGS, E. W., and KATZ, B. Mental hygiene in education. New York: The Ronald Press Co., 1941. 40. VERNON, P. E. The measurement of abilities. London: University of London Press, 1940. 41. VITELES, M. S. Industrial psychology. New York: W. W. Norton & Co., Inc., 1932.

Chapter 8 CONCEPT OF A PSYCHOSOMATIC AFFECTION By

JAMES L. HALLIDAY,

M.D.

of this paper is to indicate some of the interesting results which follow from the adoption and use of the concept of a psychosomatic affection. As a preliminary I shall define this as "a bodily disorder whose nature can be appreciated only when emotional disturbances (i.e., psychological happenings) are investigated in addition to physical disturbances (i.e., somatic happenings)." Recent research has shown that the affections covered by this tentative definition are numerous, and comprise many of the common diseases of general medicine. A list of some of these is given below. Admittedly a number of the labels embrace a diversity of symptomcomplexes differing in etiology, course and pathology, but many of the illnesses designated by these terms—the majority in respect of the "definite" items—are psychosomatic affections in the sense of the definition. T H E PURPOSE

Gastrointestinal system: Definite: duodenal ulcer; mucous colitis; visceroptosis; "stress dyspepsia" ; some cases of constipation Possible: gastric ulcer; gall-bladder disease; hemorrhoids (nontraumatic) Cardiovascular system: Definite: essential hypertension; effort syndrome; neurodrculatory asthenia Possible: some cases of coronary thrombosis; angina pectoris Respiratory system: Definite: asthma Possible: hay fever; allergic rhinitis; some cases of recurring sinusitis, recurring bronchitis, and recurring tonsillitis

m

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Genitourinary system: Definite: nocturnal enuresis; vaginismus; some cases of menstrual disturbance and of leucorrhea Possible: Some cases of pyogenic urinary infection; of uterine fibroids; of enlarged prostate; of urinary bleeding Locomotor system: Definite: many cases of "fibrositis," "neuritis," "sciatica," and "lumbago" ; also of postural defects (e.g., scoliosis, lordosis and kyphosis) Possible: rheumatoid arthritis and some nontraumatic cases of osteoarthritis Endocrine system: Definite: exophthalmic goiter, hyperthyroidism Possible: some cases of glycosuria, diabetes, tetany, obesity, and myxedema Nervous system : Definite: migraine, chorea, some cases of epilepsy Possible: paralysis agitans Blood: Possible: idiopathic hypochromic anemia Skin: Definite: some cases of prurigo, eczema, pruritus, psoriasis, urticaria, rosacea complex Eyes: Definite: some cases of chronic conjunctivitis, chronic blepharitis, miners' nystagmus Possible: some cases of childhood squint Mental (the neuroses): Definite: the innumerable bodily disturbances of anxiety state and hysteria The Psychosomatic Formulation In this list the disorders mentioned seem to be superficially unrelated and in no way connected; but further consideration reveals that many show peculiarities which distinguish them from illnesses which are not psychosomatic (such as infectious diseases, accidents and food deficiencies) and in virtue of which they possess a common "form." These peculiarities relate both to the behavior of the illnesses in time and to the nature of certain etiological factors; and they may be sum-

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marized conveniently by setting them down in a seven-point formula by means of which the concept of a psychosomatic affection becomes developed. 1. Emotion as precipitating factor.—Examination of patients in series shows that in a high proportion of cases the bodily process emerged, or recurred, on meeting an emotionally upsetting event. 2. Personality type—A particular type of personality tends to be associated with each particular affection. 3. Sex ratio.—A marked disproportion in sex incidence is a finding in many, perhaps most, of these disorders. 4. Associations with other psychosomatic affections.—Different psychosomatic affections may appear in the same individual simultaneously, but the more usual phenomenon, as revealed in their natural history, is that of the alternation or of the sequence of different affections. 5. Family history.—A significantly high proportion of cases give a history of the same or of an associated disorder in parents, relatives, and siblings. 6. Phasic manifestation.—The course of the illness tends to be phasic with periods of crudescence, intermission, and recurrence. 7. The prevalence is related to changes in the communal environment considered psychologically and socially.—The incidence of a psychosomatic affection in a community rises and falls in response to the changes of social environment, that is, to changes of environment regarded in its psychological rather than its physical aspects. Emotion as a Precipitating Factor When we investigate patients with psychosomatic affections, we find that the illness is often precipitated by an emotional disturbance which was an understandable response to a clearly recognizable disturbing event or events. Sometimes, however, the nature of the event seems petty in the objective sense and inadequate by itself to account for a profound emotional reaction in any "normal" person; but when consideration is given to the personality of the patient and to his previous life history, such minor events can often—and with good reason —be interpreted as acting as the last straw.

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Controlled investigations of a series of unselected patients have been made in a number of affections including asthma, peptic ulcer, hypertension, mucous colitis, exophthalmic goiter and rheumatoid arthritis; these indicate that in a significantly high proportion of cases the particular morbid process emerged, or recurred, when the patient met an emotionally upsetting external event or a period of abnormal stress. It may be inferred therefore that many of these persons would not have responded with their particular kind of morbid behavior— would not have taken ill when they did—in the absence of such events. In a minority no such dramatic events nor any undue stresses could be elicited from the history. All patients, however, before the onset of their illness, had shown abnormalities of disposition and difficulties with their emotional life usually extending back to childhood.

Personality Type When we meet an individual we receive certain impressions, and experience certain feelings, which provide us with a sense of the per son-as-a-whole—his total characteristics—and to this we give the name of personality. Most medical men, especially perhaps those in general practice, come, as their clinical experience grows, to sense that certain kinds of disease tend to go with certain types of person. The impression of types depends on the general configuration of the patient; on his external expression (which is a matter not only of the facies but also of attitude, posture, and manner of movement); on his "internal expressions" (as revealed outwardly in pallor, flushings, throbbings, size of pupils) ; and also on impacts that are often indescribable but which arouse intuitions belonging to the order of "hunches." Psychological investigation of disposition does, however, allow some of these hunches to be described in a communicable way. The intuitive idea that different types of syndrome or disease may be expressions of different types of personality applies especially to psychosomatic affections. Studies of personality in relation to disease have made little progress partly because of the complicated statistical procedure involved and partly because of the difficulty of ascertaining which of the innumerable aspects of a person are most relevant. A psychological approach to personality takes account of traits relating to intelligence, dispositions, and character. This approach is still being developed, but it may be said that so far no adequate method of assessing types has yet been devised. Four broad types have, however, been described.

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Hysterical or histrionic type.—This is associated with hysteria in its somatic manifestations whether sensorimotor disturbances (such as paralysis or spasms, anesthesias, or severe pains), or autonomic disturbances (such as vasomotor flushes or rashes). Hypersensitive or allergic type.—Exemplified in asthma. Self-assertive, self-sufficient, overactive, "ulcer" type.—Exemplified in peptic ulcer and certain cases of fibrositis and hypertension. Self-restricting, self-sacrificing, "rheumatoid" type.—Exemplified in

rheumatoid arthritis. Persons who develop psychosomatic affections commonly show notable obsessional trends—a term which refers to certain compulsive performances in daily routine such as always being punctual, always orderly and tidy, always very clean, always "doing one's duty"—in short, being generally fixed in one's ways and set in one's ideas. Sex Ratio A disproportion in sex incidence is a finding in many, perhaps most, of these affections. The excess is in males for some affections (e.g., childhood asthma, duodenal ulcer) and in females for others (e.g., chorea of childhood, exophthalmic goiter, gall-bladder disease, rheumatoid arthritis). This suggests, among other things, the importance of the endocrine system as a mechanism in the mediation of these affections. It cannot, however, be related to physiological sex differences only, because with changes in the social environment of a community we find the phenomenon of alterations in the sex incidence and this sometimes brings about a complete reversal of the ratio over a period of years. For example, during the last century peptic ulcer preponderated in females, but during recent years it came to preponderate definitely in males. Conversely, diabetes, which, during the last century was a disease of males, has now become a disease which preponderates in females. These facts suggest that the emotions must be taken into account in any adequate understanding of these affections. It is evident, however, that though disproportion in the sex incidence seems to be a finding for most psychosomatic organic affections, it cannot be postulated as a sine qua non of all psychosomatic disorders at all periods of time. Lastly, the sex disproportion in the incidence of psychosomatic affections is in striking contrast to the approximately equal sex incidence found in the infectious diseases.

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Different psychosomatic affections may appear in the same person simultaneously, but the more usual phenomenon is that of alternation, or sequence, of different affections. Adequate records of associated, alternating, and sequent affections are not yet available, and except for the definite grouping of asthma, eczema, prurigo, migraine, and enuresis, only occasional remarks on the subject are found in the literature. Ryle (19) in discussing the "visceral neuroses"—a term under which he includes bronchial spasm, spastic colon, and "mucous colic," functional disturbances of the bladder and rectum, globus hystericus, heartburn, and simple paroxysmal tachycardia—notes how these rarely occur together in point of time but alternate or appear at different periods in the patient's life. He contrasts the temporal separateness of these psychosomatic affections with the manifestations in human beings of anaphylactic shock in which the symptom-complexes are synchronous so that we may observe "simultaneously or concentrated within a period of hours or days" : (a) the symptoms of shock with a profound fall in the blood-pressure, tachycardia, the sense of impending death; (&) angioneurotic edema; (c) urticaria; (d) asthma; (e) gastrointestinal disturbances, usually with diarrhea; and (/) polyarthritis. Sequent Affections.—There are some casual references in published work to the time sequence of psychosomatic disorders. Wilson (25) states that exophthalmic goiter may precede the onset of peptic ulcer but apparently seldom follows it. Moschcowitz has, however, stressed the frequency of the sequence of peptic ulcer, exophthalmic goiter, and hypertension (16c). The writer has pointed out that the sequence of peptic ulcer, fibrositis, and bronchitis is not uncommon in the medical history of middle-aged insured persons who have been for long periods on the sick list (12). It is possible that the changing endocrinological setting associated with particular phases of the life cycle may be one of the factors determining such sequences. The adult, like the child, may "grow out" of one affection, but he may grow into another. Repertories of Disease.—To illustrate the phenomena of an individual's range of affections, or repertory of disease, two examples are given below. In both cases, the symptoms were responses to upsetting external events or periods of stress and strain. When one affection played Hamlet, the others usually left the stage. Any medical man will find numerous analogous cases in his everyday practice.

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CASE 1.—A man aged forty. Athletic build, pleasant, and superficially sociable. Active and full of schemes. Often incapacitated. His repertory from the age of twenty-six has included: hysterical neuritis and paralysis of the left arm; anxiety state, followed by "lumbago," which was replaced by acute religious conversion; recurring sinusitis; recurring duodenal ulcer, sometimes with severe bleeding; and finally diabetes. CASE 2.—A woman aged thirty-seven. Small, dark, with visceroptosis, tense and active and rigid in routine. Seldom incapacitated but "works on." Her repertory from the age of twenty-four has included the following, all of which have been recurrent: spastic colon, with spitfire diarrhea; floating kidney symptoms; left-sided hemicrania; sore feet; facial eruptions of the rosacea complex; hypochromic anemia with feelings of difficulty in swallowing.

Mental Disorders as Associated Affections Psychoneuroses.—A study of the natural history of psychosomatic affections shows that psychoneurotic illnesses may accompany psychosomatic organic diseases or may appear as preceding, alternating, or sequent disorders. During the course of psychoanalytical treatment a switching over is sometimes illustrated dramatically when, as a mental symptom becomes alleviated, a somatic manifestation takes its place. Such somatic manifestations are not necessarily one of the usual accepted bodily disturbances of anxiety state or hysteria but may take the shape of organic expressions such as sore throat, hemorrhoids, bronchitis, skin eruptions, or fibrositis, Idiopathic Psychoses (Schizophrenia, Manic-Depression, Paranoia.)—It has been suggested that the appearance of an idiopathic psychosis renders a psychosomatic expression unnecessary—a statement which is only partially true, since patients with these disorders often show functional disorders of the alimentary tract or vasomotor and trophic disorders of the skin, as well as abnormalities in posture. There is, however, some rather loose evidence suggesting that among sufferers from the psychoses certain common psychosomatic affections such as peptic ulcer, rheumatoid arthritis, and fibrositis are relatively rare. Psychosis and psychosomatic organic disease may alternate. I remember a woman who at the age of twenty-eight developed rheumatoid arthritis, the activity of which persisted until three years later when she became mentally affected and was admitted to a mental hospital. During her four years of residence there the arthritis was

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quiescent, but on her recovery to sanity and discharge home it recrudesced until she became completely crippled. Mental Illness and the Psychosomatic Formula.—A study of relevant data provided by textbooks of psychiatry shows that the separate mental disorders classed under the headings of the psychoneuroses and the idiopathic psychoses comply with the psychosomatic formula in respect of precipitating emotions, personality type, disproportion in sex incidence, positive family history and phasic manifestations—a finding which points to some kind of correspondence, connection, equivalence, or relationship between psychosomatic affections and mental disorders.

Family History Accurate studies of the family history in patients with psychosomatic affections are not numerous. Textbooks usually dismiss the subject by phrases such as "inheritance is important" or "a family history is common." Special investigations have, however, been carried out in a small number of psychosomatic affections set out below, and these indicate that a significantly high proportion of cases give a history of associated disorders in parents, siblings, and relatives. The method of familial transmission is still undecided. Only a proportion of a family become affected. In certain cases no positive family history is obtainable. Genetic (or Mendelian) inheritance has not been established in respect of individual psychosomatic affections, but there does seem to be inherited a kind of weakness, sensitiveness, or inadequacy. There may perhaps also be inherited a predisposition to special patterns of bodily reaction, but this cannot be stated with certainty because of the difficulty of disentangling inherited predisposition from predispositions early acquired through "psychological infection" from the parents, giving rise to habits of faulty reaction which become fixed. A psychologist described a similar idea in these words: "Parent-child resemblances in function and dysfunction need not be inherited but may arise through psychological tensions which recur in succeeding generations through unrecognized imitation and identification" (25). But whether biologically inherited or very early acquired, the predisposition seems to be woven into the structure of the personality. Finally it may be noted how common speech assumes that there are family repertories of disease: one family is "high-strung" another "queer," another has weak stomachs, another is "not strong," another "chesty."

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Phasic Manifestation The course of the illness tends to be phasic with periods of crudescence, intermission, and recurrence. Rhythmic manifestations are a feature of all life whether viewed somatically or psychologically, but in the case of psychosomatic affections the rhythm is an irregular one, as may be noted from studying over a period of time patients with peptic ulcer, asthma, rheumatoid arthritis, fibrositis, and gall-bladder disease. Each major phase of crudescence varies in severity and has no standard duration. In different people and in the same people on different occasions, the duration may vary from hours or days to months. Each stage is followed naturally by an interval of absence or subsidence, but this is of no constant length. The study of the behavior of these affections indicates that this negative phase does not necessarily represent—as is sometimes optimistically imagined— "a cure resulting from treatment." Sometimes the primary illness subsides never to return; sometimes it assumes a progressive fulminating quality; and sometimes it merges into chronicity. However, the usual course of these affections is that of irregularly phasic appearances. Investigations have shown that the irregularity in the appearance of phases of crudescence is associated with the irregularity in time of disturbing or distasteful external events. Conversely the initiation of a negative phase may be related to the removal of disturbing circumstances or the interposition of favorable happenings. "Why does he get better when he does?" is a question answered by the etiology of natural recovery. Lastly, minor phasic exacerbations or remissions are sometimes associated with cyclic endocrine activity. It is said that menstruation usually worsens the symptoms in asthma and exophthalmic goiter, whereas the endocrine "imbalance" of pregnancy sometimes brings about a subsidence of rheumatoid arthritis or psoriasis or migraine. The common clinical finding is that these diseases are phasic in occurrence. This suggests that the patient in certain circumstances contains within himself the metabolic resources for his recovery. These resources may comprise endocrine compounds. Application of the Psychosomatic Formulation The affections mentioned below were chosen solely because data relating to them were readily available. The items under the heading of personality are, however, for reasons previously mentioned, some-

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what defective. Adequate basic data for many of the psychosomatic affections mentioned in the list do not seem at present to exist. Where the origin of the reference is not given, the source of the authority is one or more of the standard textbooks of medicine. All are recognized as being phasic. DUODENAL ULCER

1. Emotion.—In serial investigation the proportion of upsetting external events at onset is significantly greater than in controls (25). 2. Personality.—Persons who develop duodenal ulcer usually show on the surface an overemphasized activity, efficiency, and independence. They are especially susceptible to threats to security (including problems relating to occupation and finance) or to the anxieties engendered by being in charge or in authority (25). Many of them show a sustained relentless application associated with obsessional and compulsive drives. All these characteristics are present very early in life (16). 3. Sex.—Three to four times commoner in males than in females (2). 4. Associated affections.—Migraine, hypertension, "fibrositis." 5. Family history of psychosomatic illness.—Four tofivetimes commoner in cases than controls. HYPERTENSION

1. Emotion.—Mental stress, excitement, and upsets are important. 2. Personality.—These patients reveal a deep-seated conflict related to anxiety. They possess hostile impulses against which they are on guard; when these emerge to consciousness, the blood pressure curve rises and falls as the material is worked through in therapy; also transitory phobic or compulsive features become manifest (10). They show external friendliness and selfcontrol beneath which there are strong aggressions and anxiety which results lest these repressed aggressions jeopardize the patient's security (1). Not being able to satisfy passive, dependent wishes nor to gratify hostile ones, emotional energy finds release only through the blood-pressure-controlling physiological mechanisms (20). These patients show an early sense of insecurity or exposure to the aggressions of the person on whom they were dependent; personality unable to function

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integratively; inadequacy against anxiety; repressive mechanism inefficient; but inability to develop an organized neurosis (3). 3. Sex.—Two to three times commoner in females (2). 4. Associated affections.—Migraine, hyperthyroidism, peptic ulcer. 5. Family history.—About twice as great in cases as in controls (8). RHEUMATOID ARTHRITIS

1. Emotion.—In serial investigation the proportion of upsetting external events at onset is greater than in controls (6). 2. Personality.—Persons who develop rheumatoid arthritis show definite emotional self-limitation and self-restriction. They tend to be independent and self-sufficient, keeping themselves to themselves. They are self-sacrificing and show obsessional trends: for example they may be overtidy, overcleanly, overconscientious, slaves to routine and with a heavily developed sense of duty (13). 3. Sex.—Three to five times commoner in females than in males. 4. Associated affections.—Psoriasis, iridocyclitis. 5. Family history.—A positive family history in 30-40 per cent of cases. EXOPHTHALMIC GOITER

1. Emotion.—In 85 per cent of over 3,000 cases there was a clear history of a well-defined upsetting external factor (8). 2. Personality.—Nervous, impatient, irritable, tending to violent emotions (8). Frustration in the normal attempt to establish independence of the mother (7). Conformist attitude outstanding; need for recognition; self-love and inability to express anger outstanding character problems; overconformance to accepted ideals is the patient's principal defense (18). 3. Sex.—Eight times commoner in females than in males. 4. Associated affections.—Diabetes, peptic ulcer. 5. Family history.—"Unusually high and includes also a family history of diabetes and nervousness" (8). FiBROsrns

This is distinguished from the pains and stiffness of hysteria and depressive states.

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CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY 1. Emotion.—"No controlled statistical studies, but frequent" (12). 2. Personality.—Not yet adequately described, but shows a correspondence with the ulcer personality; obsessional trends are not uncommon (12). Poor sleep and poor sexual adjustment are frequent features; fatigue associated with muscular aches in the presence of chronic resentment of which the patient is usually unaware (22). 3. Sex.—No reliable statistics available because of confusion between fibrositis and hysterical pains. 4. Associated affections.—Peptic ulcer, bronchitis, anxiety states. 5. Family history.—Incidence high (5).

ASTHMA

1. Emotion.—Important. 2. Personality.—An intelligence much above the average; irritable and aggressive, quick to respond; overanxious, insecure, and lacking in confidence; this hypersensitive personality stands tension very badly (17). Characterized by lack of self-confidence and need for love and protection. To compensate for this underlying tendency, various defense reactions may be employed—e.g., being very good and helping and protecting others, or, alternatively, seeking to obtain attention by particularly aggressive behavior (11). 3. Sex.—In children two or three males for every female, but in early adult life the sex incidence is equal (4). 4. Associated affections.—Eczema, prurigo, migraine, enuresis. 5. Family history.—In 30-60 per cent (4). Mucous COLITIS 1. Emotions.—Important. 2. Personality.—(a) Morphologically: among cases of spastic colon there is a preponderance of thin, spare, dark, pale persons (19). (b) There is considerable marked muscular tension, the concomitant of autonomic instability, (c) The person usually shows obsessional trends; depressions are not uncommon (24). Not unlike the allergic personality. 3. Sex.—Four to five times commoner in females. 4. Associated Affections.—Asthma, urticaria, effort syndrome. 5. Family history.—High incidence.

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CHOREA

1. Emotion.—Emotional stress, especially if of long duration, is important (15). 2. Personality.—"Nervous instability characterized by a quantitative increase in emotion and kinesis." The peculiar excitability of the chorea personality is often concealed under an overemphasized shyness. Usually above the average in intelligence (15). Has resemblances to the allergic personality. 3. Sex.—Three times as common in girls as in boys (15). 4. Associated affections.—Rheumatic fever, night terrors. 5. Family history.—Doubtful; significant in rheumatic fever, however ( 9 ) .

The Prevalence of Psychosomatic Affections A full account of the changes in age and sex incidence of certain psychosomatic affections is provided in my Psychosocial Medicine (14). This indicates that much of the "clinical material" so often subsumed under the heading of general medicine is not an eternal invariable but a function of the historical era and the social setup in which persons happen to live and physicians to practice. Conclusion The concept of a psychosomatic affection in its developed form brings into relationship a large number of seemingly unrelated facts. The outlook gained shows that many "localized diseases," the names of which have hitherto been found scattered throughout textbooks of medicine under the headings of the various anatomical systems, may now be grouped under a unifying etiological category. The term "psychosomatic affection" is therefore a valid symbol which provides a new instrument for thinking, for investigation, and for the direction of action. It is interesting to note how medical workers in other fields are arriving at a concept similar to that of the psychosomatic affection. Terms which would seem to show some loose correspondence with it are those of "stress diseases" and, more recently, "diseases of adaptation." In connection with the latter Selye (21), mainly as a result of animal experimentation, has shown the importance of various endocrinological imbalances in connection with syndromes corresponding to the psychosomatic affections in general. The stresses to which the

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animals were exposed included extremes of heat, cold, starvation, and fatigue. In modern communities of Western civilization, these stresses seldom operate, but those which do are predominantly the ones which are the concern of psychosocial medicine. REFERENCES 1. ALEXANDER, F. Emotional factors in essential hypertension. Psychosom. Med., 1939, 1, 173-79. 2. BELL, J. Ann. Eugen., Camb., 1940, 10, 379. 3. BINGER, C. A. L., et at. Personality in arterial hypertension. New York: The American Society for Research in Psychosomatic Problems, 1945. 4. BRAY, G. W. Recent advances in allergy. London: J. & A. Churchill, Ltd., 1931. P. 181. 5. BUCKLEY, C. W. (ed.). British encyclopaedia of medical practice. London, 1938. Vol. V, p. 279. 6. COBB, S., BAUER, W., and WHITING, I. Environmental factors in rheumatic

arthritis. / . Amer. med. Ass., 1939, 113, 668-70. 7. CONRAD, A. The psychiatric study of hyperthyroid patients. / . nerv. ment. Dis., 1934, 79, 505-29. 8. DONNISON, C. P. Civilisation and disease. London: Tindall & Cox, 1937. 9. DRAPER, G. Disease and the man. New York: The Macmillan Co., 1930. 10. DUNBAR, F. Emotions and bodily changes. New York: Columbia University Press, 1938. 11. FRENCH, T. M., and ALEXANDER, F. Psychogenic factors in bronchial asthma, Part I. Psychosom. Med. Monogr., 1941, No. 4. 12. HALLIDAY, J. L. The concept of psychosomatic rheumatism. Ann. intern. Med., 1941, 15, 666-77. 13. . Psychological aspects of rheumatoid arthritis. Proc. roy. Soc. Med., 1941, 35, 455-57. 14. . Psychosocial medicine: a study of the sick society.. New York: W. W. Norton & Co., Inc., 1948. 15. HUBBLE, D. The nature of the rheumatic child. Brit. med. J., 1943, 1, 121-25, 154-58. 16. MITTELMANN, B., and WOLFF, H. G. Emotions and gastroduodenal function. Psychosom. Med., 1942, 4, 5-61. 16a. MOSCHCOWITZ, ELI, and ROUDIN, MATAB. The association of psychosomatic

17. 18. 19. 20. 21. 22. 23.

disorders and their relationship to personality types in the same individuals. N. Y. State Jour. Med., 1948, 48, 1375-81. ROGERSON, C. H. Psychological factors in asthma. Brit. med. J., 1943, 1, 406-7. RUESCH, j . , et al. Psychological invalidism in thyroidectomized patients. Psychosom. Med., 1947, 9, 77-89. RYLE, J. A. Visceral neuroses. Lancet, 1939, 2, 297-301. SAUL, L. J. Hostility in cases of essential hypertension. Psychosom. Med., 1939, 1, 153-61. SELYE, H. The general adaptation syndrome and the diseases of adaptation. Practitioner, 1949, 163, 393-405. WEISS, E. Psychogenic rheumatism. Ann. intern, ed., 1947, 26, 890-900. WEISS, E., and ENGLISH, O. S. Psychosomatic medicine (2d ed.). Philadelphia: W. B. Saunders Co., 1949.

24. WHITE, B. V., COBB, S., and JONES, C. M. MUCOUS colitis. Psychosom. Med.

Monogr., 1939, No. 1. 25. WILSON, A. T. M. Psychological observations on haematemesis. Brit. J. wed. Psychol, 1939, 18,112-21.

Chapter 9 GUIDE TO INTERVIEWING AND CLINICAL PERSONALITY STUDY By JOHN C. WHITEHORN, M.D.

Learning About the Patient's Attitudes HUMAN PSYCHOBIOLOGY, which is concerned with the integrated adaptive behavior of the human being, is of major importance in all fields of medicine. It is a fundamental purpose of psychiatric instruction and training to help the physician learn how to deal with the psychobiologic unit—the person—in action. The primary technical psychiatric procedure is the interview between the physician and the patient. The aims and methods of psychiatric interviewing can be learned thoroughly only by experience, reflection, and discussion with teachers, but a somewhat detailed discussion of the matter is offered here for preliminary guidance. The universal aim of the physician at the beginning of the first interview with the patient in any case is to learn about the presenting problem, or chief complaint. Thereafter, aims diverge somewhat. One line of inquiry tries to answer the questions, "What noxious agent causes this patient to be ill; how does it do so, and how can it be eliminated?" Another line of inquiry concerns the patient himself, "What is his reaction to the noxious influence, or influences, and how can a knowledge of his personality be utilized in his care?" This study of the patient as a person acquires an enormous importance in certain instances from a surprising fact: The patient is often his own worst enemy. His attitudes are sometimes the most noxious agencies with which the physician has to contend. The primary purpose of this guide is to help the physician to use the interview as a method of eliciting and evaluating patients' attitudes. It is not concerned primarily with the pathologic phenomena which should be noted in making a differential diagnosis. Its purpose is to aid the physician in the more difficult task of understanding the personality of the patient who is under study. Emotional reactions, which are expressions of the personality, play an important part in a 187

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wide range of medical and surgical conditions, not merely in psychotic or neurotic disturbances. Expertness in employment of the interview for this purpose is a universally useful medical skill. In the use of this guide in the development of skill in interviewing for the purpose of personality study, it is recommended that the student first read it over quickly for general orientation and then review various sections repeatedly in close relation to work with actual patients. The clinical study of personality depends fundamentally on the physician's first-hand study of the patient's attitudes. Sometimes the matter is left at the level of his getting a few opinions about the patient from relatives or other sources, but this information is inadequate and often misleading. To learn about the patient's attitudes is somewhat more difficult than to make a physical examination, largely because of two factors: First, the factual information sought is somewhat more subtle than that which the examiner seeks through inspection, palpation, percussion, or auscultation; and, second, the technic involves the "personal equation" to a much more important degree. Indeed, one may truly say that the personal interaction between examiner and examinee constitutes the most vital part of this examination. The examiner must be doing two things—he participates in the interview and he observes at the same time. For purposes of logical discussion, these two roles may be separated, but in actual work they have to be combined.

Elementary Steps GETTING THE INTERVIEW STARTED

In learning to interview patients, one is inclined to depend on a prepared series of questions or topics, to "cover the ground" for one's superior; and it remains always a valuable aid to thoroughness to have in the back of one's mind, or in the back of one's desk, some scheme of systematic survey. The psychiatric textbooks give outlines which are particularly designed for the examination of psychotic patients, and special treatises on this subject are available, for example, Cheney (1) and Preu (4). Yet mere questioning, in an impersonal and completely unresponsive manner, tends to defeat the examiner's purpose of learning about the patient's attitudes, for patients do not talk revealingly to an interviewer who does not show signs of interest and of increasing understanding, that is, unless what the patient says seems to mean something to the interviewer. The patient's attitudes are not likely to appear at first, in answer to prepared questions, but later, in reaction to what he feels is the interviewer's response to his

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statements. Some response is needed to draw the patient out. The responses most helpful in eliciting significant statements are, in general, facial expressions and gestures—the ordinary human signs of interest and appreciation. The interviewer need not talk a great deal, and he surely does not need to begin forming and stating opinions. If he does have to talk a bit to get the patient started, he needs to be alert to what may be suggested thereby. Letting the patient tell his own story is the best way to avoid the troubles that arise from suggestibility. An attitude of alert interest and appreciation is the best means of avoiding the opposite extreme of having the patient "freeze up." Furthermore, every interview has its psychotherapeutic or psychonoxious implications. It is incorrect to think that the examiner can first gather the information and then start the psychotherapy. The psychotherapy begins at the very first contact, in the sense of a mutual understanding and rapport. This does not mean that the interviewer has to start at once to offer advice and opinion—far from it. T H E PRESENTING PROBLEM AND THE PRESENT ILLNESS

With relatively few exceptions, interviews begin with the presenting problem, corresponding to the classic medical term "chief complaint." The presenting problem is likely to be the topic which provides the soundest basis for a conversation of mutual serious interest. Why did the patient come to the hospital, clinic, or physician ? What circumstances led to his coming at just this time? Had everything been going well up to this time ? The examiner should be sure to record verbatim the sentence in which the patient expresses his chief complaint. The manner in which this is stated generally indicates not only the chief complaint but the patient's attitude toward it, the record of which is lost if the complaint is translated into medical terms. Furthermore, all subsequent discussion is likely to revolve around this chief complaint; so it is a great help to be able to refer to it just as the patient stated it. The story of the development of this chief complaint from the time the trouble began (the "present illness," as it is designated in the record) is usually the next topic to arise; here, again, the form of the patient's statement is important, although it is usually necessary to condense it for the record. Some patients may say, "Well, doctor, you saw my record" or, "You saw my sister" or, "Do I have to go over all that again?" It may help, then, to say, "Yes, but we want most of all to know your

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story of the matter" or, "We need to understand how the situation has been affecting you—your life, your feelings, your activities or your welfare." It is of chief importance to get the patient's own formulation of the presenting problem. This will tell the physician a good deal about the patient himself, as well as about his sickness. The patient should also be encouraged to tell what he expects that the physician or the hospital can do about this presenting problem and what kind of help he is prepared to receive. Patients are seldom aware of all the resources of the medical profession. A patient who feels only moderately ill may say, "Well, doctor, maybe I need only a pill." Another, feeling gravely ill, may say, "Maybe I need an operation." Some patients find it difficult to accept the kind of help that can, and should, be given. So it is necessary to get an idea of what the patient expects and is ready for and the attitudes which must be met in gaining acceptance for the proper therapeutic measures. SIMPLE TESTS OF MENTAL EFFICIENCY AND OBSERVATIONS ON MOOD

No general discussion of mental tests is given here since the primary purpose is to assist the interviewer in establishing rapport and in evaluating the dynamic features of the personality. A few simple suggestions are offered, however, which may serve as a means of quick orientation and as an aid in the tactful establishment of an acceptable basis for further mental tests. These suggestions are of special importance when there is reason to think that the patient is psychotic. After a certain portion of the interview has brought into discussion some of the patient's troubles, it may be appropriate to inquire, "While you have been anxious and uneasy about this condition, how has your work been going?" The answers to such a question will often reveal much more than the patient intends to say about his attitudes toward his responsibilities. The examiner may then ask, "With this trouble on your mind, have you had difficulty in concentrating on your work ?" Since nearly every one does at times have difficulty in concentrating, some kind of an affirmative reply is usually given although perhaps vague and qualified. Then the interviewer can appropriately say, "Well, I have a little test for concentration which I would like you to do, in the way of mental arithmetic. First, subtract 7 from 100." When the answer has been given as 93, say, "Now subtract 7 from that." When that answer has been given, say, "Now, go right on subtracting

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7 each time, without my interrupting you." The examiner does not interrupt except to nod or to say "Go on," unless the patient is floundering badly. If the patient has done well (all the answers having been given correctly, within one-half or three-quarters of a minute), the examiner may ask, "Is that the correct remainder?" It should be noted whether the patient checks his work by dividing 100 by 7 (2). In accordance with the patient's ability to keep oriented to the task at hand through this performance, the examiner may then inquire appropriately about general orientation, e.g., "Do you have any (or similar) difficulty in concentrating on practical matters, such as keeping track of current events—of time?—of your meals?—of people's names?—of where you are?" If he is uncertain, he should be asked for specific answers. The presentation of this series of tasks to the patient as having to do with his ability to concentrate is psychologically reasonable. It has, also, the advantage of permitting efforts and failures without severe loss of self-esteem, since every one can admit difficulty in concentrating at times, whereas he might feel insulted by the bald questions. Appropriate situations may occur during these "concentration" tasks for the question, "When you have difficulties in concentrating, are you distracted by other thoughts?—by noises?—by imaginings?" Then the examiner may ask, rather vaguely, "Have you had any strange or unusual psychic experiences ?" or, more bluntly, "Do you hear voices—or see visions—or receive messages—in uncommon ways?" These suggestions afford a minimal scrutiny of the more outstanding psychotic symptoms if present. Observations on general behavior and the style and tempo of talk and activity should be noted; they may form the basis for the evaluation of such moods as sadness, fear, and elation. Disorders of mood are usually reflected, also, in disturbances of sleep, appetite, and bowel function. DEPRESSED STATES AND THEIR INFLUENCE ON THE INTERVIEW

When the patient is found to be in a sad mood or is gloomily irritable, consideration should be shown for his thinking difficulty. An apparently simple conversation may be overwhelmingly difficult for the retarded patient. It is the moderately or mildly depressed patient who is most likely to have this feature of his condition overlooked, and who therefore runs the greatest risk of being exhausted by an

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unduly complex or prolonged interview. An exhausted, depressed patient may be a source of much misinformation, either because he misunderstands the context of a discussion or because, in order to be spared further effort, he may answer "yes" to any question or, in an undiscriminating way, disagree with everything. ROUTINE QUESTIONS AND EXAMINATIONS

The discussion of the chief complaint and the present illness will often bring spontaneous statements on many of the points of information needed for the medical record, but some points will usually be left untouched. When a measure of rapport and mutual understanding has been reached through some minutes of rather informal and spontaneous interviewing, the examiner will usually find it acceptable to change the pace and style of the interview in order to complete the routine information. He may say, "Now I have some specific questions to ask you about your past life. When and where were you born? What illnesses or operations have you had? Where and when?" and so on, through the usual simple questions about school, jobs, marriage and children, and social and economic circumstances, including, in a matter-of-fact way, questions about habits (use of alcohol and tobacco and sex experience). The patient may be asked for a simple self-evaluation of his personality traits (whether he is reserved, moody, tense, excitable, or steady). With regard to the family history, the examiner may at first quickly review the ages and general health of the parents and siblings and the occurrence of any illnesses among them comparable in the patient's eyes to his own condition and later expand the inquiry as needed for the biographic understanding of family relationships. Information from other persons may be required to complete, supplement, or check the patient's account. For an adequate personality study, the biography of the patient is, next to actual interview and observation, the most important source of information. The art of biography for medical purposes is not specifically discussed here, but later sections deal with many of the principles involved in it.

Special Aspects of Interviewing COMMON DIFFICULTIES IN PSYCHIATRIC INTERVIEWING

The examiner should avoid getting into unprofitable arguments with a patient. Some patients, especially those with a chronic, ob-

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scure disease, or a neurosis, may put an uncomplimentary interpretation on any evidence of interest in their personal reactions, saying "So you think I'm abnormal, do you?" or, "Do you think I am only imagining these things ?" Such remarks may at times be turned to advantage by asking, in turn, " W h a t suggested that to you ?" Whereupon the patient may tell of relatives, friends, or physicians who have "accused" him of being neurotic. The physician's quizzical eyebrow or his repetition in a questioning tone of the word "accused" may then elicit a revealing rush of self-defensive remarks about "misunderstandings" over what some one may have called "imaginary" illness or over a lack of appreciation of the patient's trouble. Sometimes a patient may sink or retire into a bog of tearful selfpity or self-defensiveness and need a bit of assistance in climbing out or a bit of stimulation. Restraint and discretion should be exercised in order not to overdo it. If the examiner has already picked up some facts of encouraging or appreciative potentialities, he can bring this knowledge into play at this point. H e may say, for example, "But, in spite of these difficulties and misunderstandings, I understood you had kept active in the care of your home (or in church duties, or looked after your sister's child, or were secretary of your club)." It is well to be specific in such remarks as in any questions concerning successes and achievement. A generalized question about such matters can be disheartening to one who cannot at the moment recall any achievements. Sometimes a patient may stick on the issue that the physician thinks him abnormal. If it is not possible to get around this point unobtrusively, the examiner may say something like this, "I had not thought particularly that you were 'abnormal' (or 'imagining things' or 'neurotic,' or whatever point the patient has raised) but just that you are human, and as a doctor I am of course concerned about how your human interests and activities affect your illness and your health. It is a necessary part of my business to learn about such matters." The experienced interviewer will sometimes find it an advantage to acknowledge promptly, if it is true, that the patient's behavior or remarks have raised in his mind the possibility that the patient has become seriously handicapped by depression or has been confused or is jumping to conclusions too quickly, and will remark, "Well, you do seem depressed," or, " W h a t you have just said sounds very strange to me," or, "Well, maybe so, but tell me more, so I can better understand your difficulty."

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Some patients do not need such careful maneuvering to get them talking about their sickness and themselves. Indeed, some physicians who are untrained in using the interview for personality study complain at times of the patient who talks too much, who "hands out just a lot of circumstantial and irrelevant talk." If one is studying the personality of a patient, there is no such thing as "irrelevant talk." The irrelevance is merely a condition of the interviewer's mind—he doesn't know what to make of it. The observer may listen, out of politeness, or because he has been told there is psychotherapeutic value in letting the patient talk, but he may not know what to listen for; in that case, the psychotherapeutic value may not be very great, for the patient may sense that no progress is being made. The inexperienced interviewer may wonder how he can get the facts required for a respectable case record while letting the patient ramble. It is sometimes necessary to sacrifice the value of an unobstructed statement in order to hasten along to some other task. Actually, however, much of the information needed will come out spontaneously, and opportunities will also arise spontaneously for the necessary factual questions, such as those concerned with ages and names and the relationships of parents, siblings, and others. The interviewer will often find it distinctly helpful to pick up promptly the familiar names of persons as they are spontaneously mentioned. A relatively few seconds of intense effort, applied successfully at the first opportunity, in learning names and chronologic sequences may gain him a rapport with the patient which is worth hours of subsequent effort. Without getting into deeper meanings at this stage, I may say that the patient's "irrelevant talk" usually means that he feels the need of self-justification, for some reason or other. To discover the "some reason or other" may be sometimes of much greater medical importance than anything else the physician can do. He should not, therefore, merely wait for the talk to subside or impatiently brush it aside. He should get down at least a few sentences for careful study. The interviewer does well, in general, to keep his mouth shut and his mind alert to all evidences from which he can infer the nature of the implied accusation or guilt against which the "irrelevant talk" or behavior constitutes a defense. He has the opportunity to learn in this way what "it is all about," by a process somewhat analogous to the surveyor's triangulation, thus: He may take two statements of the

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patient and imaginatively construct a statement to which they could be the logical replies. If a considerable number of these construction lines converge toward the same point, the interviewer thus acquires a tentative idea as to what the talk is all "about." H e may even throw out tentative questions or remarks to check his inferences. It is not recommended to seize the patient, so to speak, and make him face this central issue. In whatever the interviewer says, he should keep to the same tangential lines which the patient has already laid down and use so far as possible words which the patient has used. Skill in such "triangulation" is gained by close attention to detail and careful review of recorded interviews. T H E INTERVIEW AS A CONSTRUCTIVE EXPERIENCE FOR THE PATIENT

The aim of this chapter is primarily to aid the student of medicine as clinical clerk or intern in the task which to him is paramount. That task is, primarily, the diagnostic responsibility of arriving at a sound knowledge of the patient and an insight into his condition and reactions. Nevertheless, it should be clearly recognized that the interview between patient and physician may have meanings for the patient which are quite different. W h y should any patient wish to carry on an interview ? The student's common sense tells him that the patient should wish to cooperate in order to establish a correct diagnosis, and the patient may, of course, acknowledge the logic of this proposition and yet be impatient, and a bit emotionally resistant, about what may seem unnecessary personal exposures. The most general and reliable incentive for the patient's participation in interviews is the desire for understanding and an appreciative response. Frequently this desire is a stronger motive than is the desire to cooperate with complete truthfulness for the purpose of getting relief from pain or other symptoms of illness. The physician comes to expect a certain amount of falsification and deceit, as automatic human reactions, not to be viewed with too much indignation. The "rate of discount" varies with the patient and, also, with the rapport. W h e n the interviewer senses keenly the patient's need for understanding, it is a common error to say hastily and reassuringly, "Yes, I understand," when, in fact, he does not understand. Such empty reassurance defeats its own purpose and blocks further progress. Real understanding, useful to the patient, is best shown in appreciative listening, with brief comments and questions geared

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closely and simply to the theme of the patient's preoccupations. Courtesy and respect shown in this way need not excessively prolong the interview; in fact, the session is often thereby speeded up and brought around to certain objectives of the interviewer much more promptly and effectively than by his keeping the patient crowded to the wall by a barrage of questions. In any interview which invites spontaneity, the person interviewed may make constructive use of the opportunity to gain a better perspective and orientation. In therapeutic interviews this opportunity is systematically developed and used. Through the respectful, but candid, interaction between the attitudes of the two participants, knotty problems may be untangled with much greater effectiveness than in any purely logical analysis. In this sort of work the interviewer needs to have a fairly sound understanding of his own attitudes as they bear on the patient's problem, lest he impose new difficulties on the patient. T H E IMMEDIATE SITUATION AND THE PATIENT'S ATTITUDE TOWARD IT

The foregoing suggestions have been formulated primarily as aids to the physician in starting an interview with a new patient in the out-patient department. If the patient comes to the interview from a psychiatric ward, or is interviewed right in the ward, there will of course be a somewhat different set of expectations to deal with. The patient may be guardedly self-defensive, or he may be openly selfassertive, with delusional material prominently thrust into the foreground ; and the interviewer may be blinded to the real opportunity for understanding because of prejudiced or inadequate conceptions of what such behavior means. On the other hand, if the patient is in a surgical or an obstetric service, both he and the interviewer are likely to have quite another sort of expectations and may perhaps be temporarily blind to the importance of emotional factors. Even if informed by an instructor in advance that the patient's condition has been classified in a certain diagnostic category, the interviewer has still a natural opportunity to inquire about the individual patient's manner of experiencing this illness in his own individual way and his manner of meeting the problems presented by the illness. There is always, therefore, some appropriate route by which to open a pertinent discussion of personal issues, if only ingenuity and tact are skilfully utilized. The patient usually finds himself, by reason of his illness—whatever it may be—in a state of unaccustomed helplessness. How does

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he take this? He may be chagrined or embarrassed about it and strive to minimize his helplessness, or he may welcome the invalid state. The manner in which a patient, in the situation of dependency imposed by illness, accepts or solicits sympathetic consideration may provide ready clues to his aptitude for the invalid role. In some persons this aptitude for invalidism is great indeed at all times, and it may be the main difficulty with which the physician has to contend. Or it may be that a tendency to welcome invalidism may represent only the need to escape from a temporary, but unusually harassing, set of anxieties. The physician's awareness of the need to evaluate such a factor will ordinarily lead to inquiries as to the patient's responsibilities. At the same time, he will feel the need to frame the discussion in terms acceptable to the patient and so will find himself discussing occupational fatigue or social position or the children's school difficulties, not as irrelevant intrusions in the history-taking, or as separate and unrelated items, but as integrally related and medically significant affairs, pertinent to the evaluation of the patient's capacity to tolerate responsibility and anxiety. The physician's preparedness to gain significant insight into the patient's needs and difficulties through discussion of the patient's anxieties depends largely on his understanding of the psychologic and physiologic function of anxiety and the various human reactions and defenses against anxiety. For this reason, these suggestions for interviewing are supplemented here by a review of the dynamic considerations involved in dealing with anxiety. Summary In a brief summary of all the preceding elementary discussions, it may be said that, in whatever conditions the personality of the patient is considered to constitute an important factor in the causation or the management of his illness, the examiner should seek, preferably through interviews with the patient himself, to establish the following points: (a) the patient's own spontaneous statement of his presenting problem (or "chief complaint") ; (b) the special pressures in the patient's situation—personal, economic and social (including legal, political, and military factors)—and the patient's attitudes thereto; (c) the way in which the patient's responsibilities or anxieties are increased or decreased by the illness; (d) the patient's general predisposition or resistance to the invalid state; and (e) the attitude of the patient to the physician, the hospital, etc.

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Dynamic Considerations in Personality Study The preceding suggestions for the interview of patients cover only the most elementary aspects. For more penetrating and significant progress in clinical personality study, one cannot well depend on preformulated detailed suggestions. It is more helpful in the long run to have a clearly formulated conception of the varieties of ways in which the medically important features of personality are developed and come to expression. Good descriptions of the observable patterns of various personality disorders are available in all the modern textbooks of psychiatry. Many of these manifestations show clearly in direct reactions to the interview and the examination by the physician; other features come to light in the review of the patient's life. In the preparation of this outline, it is assumed that the user has available a good descriptive textbook and clinical cases for examination and study. Since this guide is oriented toward therapeutic aims, the considerations presented here are shaped to help the physician in getting a grasp of the dynamic personal forces manifested in the clinical phenomena. The viewpoint here is functional, rather than symptomatic. The aim is to help the examiner in utilizing the interview to gain an understanding of how the patient has been reduced to a second rate mode of adjustment and why he may be inclined to remain slumped in a relatively maladjusted state, rather than to endure the distress and anxiety involved in risking attempts at a better personal adjustment. Such an understanding, if obtainable, enables the physician to fit the therapeutic strategy to the situation and the person. In the focusing of attention on the biographic development of personality trends, the reader is cautioned against the tempting fallacy of attributing the sole cause of an episode of illness to any single dramatic personal event or impersonal trauma. It is wise to remember how intricately the integrative mechanisms operate in bringing a multiplicity of influences to bear on behavior. Reaction is determined both by attitude and by circumstance, and in the shaping of attitudes single events become significant through relation to the whole course of the personality development. RELATIVELY SIMPLE REACTIONS OF ANXIETY

Anxiety; Its Effects and Antidotes Anxiety—the condition of heightened tension, usually associated with fear or excitement—is a universal human experience of great biologic importance, both for good and for ill.

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On the good side, anxiety mobilizes physiologic mechanisms for violent activity and puts one's faculties "on the alert." Anxiety may even do some good at times in the very respect in which its effects seem worst, that is, in interrupting and disorganizing a pattern of action, for this disorganization of a pattern may jar one out of a rut unsuited to the demands of the moment and open up the possibility of more appropriate behavior and attitudes. Whether or not such a new possibility will be realized will depend of course on other features of the personality and on the situation. Within limits, and when concerned with issues which are tolerable to one, such disturbing events may serve as useful stimulants to the growth of personality. On the bad side, when anxiety is excessive or too prolonged, it may too thoroughly interrupt and disorganize one. The physiologic mobilization in anxiety, if prolonged and unused, may expend one's resources and seriously disrupt the automatic regulation of the body, particularly in the gastrointestinal, circulatory, and respiratory systems. The natural antidote to anxiety is action—definite and specific action, designed to overcome or eliminate the source of anxiety. The relief from anxiety through action is not usually delayed until the source is overcome. Vigorous and aggressive action may itself dispel anxiety, sometimes almost in a flash. Hence, for example, the desirability for soldiers of thorough training and drill, so that action may be prompt and vigorous. By providing release through action, one may, if the action is appropriate, make an asset out of the increased tension of the anxious state, rather than permit it to blow up into demoralization. Because action in itself, even relatively futile action, has some value in reducing anxiety, many persons drift into habits of resorting to certain set activities when anxious—activities which range in complexity from simple tics or an embarrassed laugh or twiddling a watch charm to the most elaborate obsessive rituals. In the course of the life experience, particularly in early childhood and in adolescence, the anxiety and tension associated with fear and excitement may become associated, almost as in the conditioned reflex experiment, with specific emotional and visceral reactions, such as disgust, vomiting, loss of appetite, and trigger-like reactions of the sexual system to specific stimuli. Common examples of such combinations of behavioral and visceral disorders, associated with anxiety are found in fastidiousness toward food, easy disgustability, dizziness, and even amenorrhea, as illustrated in anorexia nervosa. Excessive motor and secretory reactions

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of the stomach or colon are also frequently caught up in such associated patterns, with rather specific emotional connotations and in correlation with definite personality trends. There is more than merely verbal similarity in defecatory and desecratory impulses. Physicians, because of their professional preoccupation with problems of life and death, are apt to assume that the fear of death is the great common denominator of anxiety. This is probably not true. Even in deadly warfare one's greatest apprehension is not of death but of being maimed or of failing in one's duty and that, in large part, because one dreads the reactions of other persons. In common clinical experience, when the physician has to deal with recurrent states of anxiety, or with certain second-rate, self-defensive reactions habitually utilized for minimizing anxiety, it is most commonly found that the anxieties arise out of interpersonal relationships and interpersonal attitudes. Even financial worries are not concerned simply with money—they have to do with one's obligations and responsibilities to other persons and the attitudes of other persons. People differ enormously in their capacity to tolerate anxiety. Some recoil from almost any anxiety situation; others accept an anxiety experience as a necessary feature of real living and "sweat it out" as well as they can. For many persons, anxiety and its immediate and remote repercussions disturb physiologic functions to a degree which may be experienced as an illness, or in a manner which seriously complicates other illnesses. Particularly for those not endowed with abundant vitality and enthusiasm, recurrent anxiety and tension may spell the difference between fairly good health and incapacitating illness. Simpler Physiologic Expressions of Anxiety, Their Detection and Treatment—A considerable number of persons who come for medical study and treatment present symptoms which are nothing more than the regular physiologic expressions of anxiety. With the inevitable tendency to self-diagnosis, these symptoms may have been formulated by the patient as "stomach trouble" or "heart trouble," and through introspective exaggeration and hearsay these self-diagnosed conditions may be supplied with an additional layer of suggested signs and symptoms. It may require much examination and testing to rule out such plausible misunderstandings. The initial interview gives an opportunity for the observation of simple and useful signs pertinent to the detection and evaluation of anxiety, such as moist hands, mopping of sweat from the forehead, tense postures, fidgety movements of the hands or feet, uneven or strained voice, swallowing movements, wide pupils, excessive vigi-

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lance or preoccupied inattentiveness and general restlessness, with their topically determined fluctuations. The treatment of wet palms, tightness in the throat, or tachycardia which originates in anxiety proceeds effectively, not by the application of remedies to the palms, the throat, or the heart, or indeed by the application of remedies at all, but by the resolution of the sources of anxiety. The same principle should be borne in mind in dealing with the more complicated neurotic mechanisms. Therapeutic strategy is better directed toward helping the patient deal effectively with more fundamental difficulties—usually difficulties in personal adjustment. With a certain proportion of patients, the whole business of psychiatric interviewing and personality study—and of treatment also— may be comprehended in a fairly simple interview. The patient may be given some authoritative help in understanding that his condition has developed in part through the results of anxiety, and he may be aided in a simple way in focusing his capacities on a proper solution of the problem which is responsible for the anxiety. If the patient can then promptly and effectively deal with the cause of anxiety, this may be all the psychiatric interviewing that is necessary to help him to the cure of his physiologic upset Hindrances to the Simple Management of Anxiety Effects.— Unfortunately, simple enlightenment about anxiety may not be enough to get the patient on the road to health. This may be because the anxiety-producing situation is in itself too difficult for the patient to solve, or because certain attitudes of the patient hinder his attempts at its solution, or because the patient's anxieties actually arise out of certain attitudes which reproduce the same sort of situation again and again. Under such circumstances, the psychiatric interview has to reach another level of subtlety. In general, it is foolish to be more subtle than is necessary. Many of the subtleties of psychiatric interviewing are required only in the most difficult cases, suitable only for the highly trained specialist, but there is a considerable range of mild forms of personality disorder, involving only a moderate complexity of the personality functions, which can be disentangled, helpfully formulated, and greatly relieved through a relatively modest understanding of certain common self-defensive reaction patterns. NEUROTIC DEFENSES AND THEIR RELATION TO EVERYDAY LIVING

Common Defenses Against Anxiety and Their 111 Effects,—

It is a common observation that chronic tension or acute anxiety arises from dissatisfaction, and that dissatisfaction comes from the

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nonsuccess of one's undertakings. As a rough approximation to the truth, it may be said that success brings satisfaction and failure brings dissatisfaction. But without aspiration or ambition, there is no keen experience of failure. The formula for satisfaction might be expressed better as a ratio—the ratio of achievement to aspiration. Even great achievement may leave great dissatisfaction if it falls too short of one's aspirations. This formula is not quite adequate, either, because it implies, mathematically, that great achievement with slight aspiration should give huge satisfaction, which is not altogether true. But the principal reason for the inadequacy of such simple formulas for satisfaction or dissatisfaction lies in their failure to take into account the great importance of one's emotional relationships with other persons, from which, in fact, arise the greater part of one's satisfactions or dissatisfactions. An adequate statement must include such considerations. To include them, it may be said that satisfaction, in human life, is gained through successful self-expression in a manner which maintains emotional security and self-assurance through the affection and respect of others. This complicated formula is not fulfilled for anyone 100 per cent of the time. Some persons, emotionally insecure, find themselves regularly inhibited in self-expression because of paralyzing uncertainty as to the affection and respect in which they are held, but may burst out spasmodically at times in awkward and ungracious selfassertion ; others, overprotected and overindulged, may acquire offensive habits of self-assertion through lack of an appropriate milieu for the development of their responsiveness to the feelings of others. The failure, in any given event, to meet all the conditions of this formula for satisfaction commonly produces anxiety or depression. Such anxiety may be a useful experience, spurring one to better effort next time. On the other hand, depression may, also, be a helpful experience, in leading to a more temperate exertion and a more moderate aim. But either anxiety or depression, or a combination of the two, is unhealthy if it is so excessive or prolonged as to prevent integrated effort. Such pathologic anxiety or depression may be called primary psychopathology, for convenience of discussion, to assist in the consideration of secondary psychopathologic reactions, namely, certain neurotic defenses against depression and anxiety. These are psychobiologic devices which protect one's self-esteem in secondrate fashion—a sort of automatic avenue to consolation. Perhaps the simplest of these automatic face-saving maneuvers are the hypochondriacal and neurasthenic complaints, sickness and fatigue being almost universally acceptable excuses for nonperformance, as well as

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means for gaming attention and pity. Attention and pity are desirable interpersonal supports to emotional security—not so good as respect and affection, but still worth while if one cannot have a full measure of the more desirable responses. (In later sections some of these neurotic defenses will be briefly discussed.) From the medical point of view, the neurotic defense reactions have two undesirable features: First, they are, so to speak, habitforming; that is, they dull the psychic pain of failure or insecurity, with considerable substitutive gratification, and so tend to .be repeated again and again; second, they are not altogether satisfying, since they do not provide good support, from the emotional responses of others, to one's feeling of self-assurance but tend to produce complications of shame, disgust, resentment, dependence, rebellion, and other mixed feelings, which, again, stir up anxiety or depression and so establish a kind of vicious circle, like the drunkard's remorse, which can be drowned only in further alcoholic oblivion. Two elementary principles of psychotherapeutic treatment follow directly from these considerations and may conveniently be mentioned here: First, it is desirable to help the neurotic patient rediscover and utilize capacities and interests the expression of which may lead to more genuine gratification; and, second, in some of the more difficult cases the physician may have to carry out a more fundamental procedure by going back to items of "unfinished business" in which the neurotic pattern was resorted to and helping the patient complete the business in a more permanently successful and gratifying way, compatible with a reasonably high measure of self-esteem, and therefore not requiring neurotic self-defense. A third principle must also be carried in mind in any attempt at the more radical treatment of neurotic persons, namely, that the neurotic defenses, troublesome and hindering as they may be, have considerable value in maintaining some kind of stability, and the therapeutist should not attempt to blast them away without careful provision of other supportive measures and thoughtful consideration of the patient's alternative modes of adjustment. It is probably fortunate that neurotic adjustments are rather resistant to change. Otherwise, overenthusiastic psychotherapeutists, lacking in wisdom, might do more harm than good. "Compensated" and "Decompensated" Neuroses.—In clinical medicine one finds not infrequently that a seriously crippled heart may nevertheless perform adequately its necessary functions. The heart is then said to be compensated. The person may carry on at a somewhat reduced level of activity without distress. In a somewhat com-

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parable way, the neurotic person may have developed an adjustment to life—maladjustment though it may be—which enables him to carry on without great distress. Obsessive scrupulosity is a common form of such adjustment whereby anxiety or feelings of guilt are kept at a minimum. The hypochondriacal domination of a household may, likewise, keep one "compensated" in this sense. On occasions which threaten such adjustments or which call heavily on one's capacities for interpersonal relationships, such "compensation" may break and a state of considerable anxiety develop. In a figurative way, this condition may be characterized as a "decompensated neurosis." Since it is usually just such a "decompensated" state which drives one to the physician for help, most neurotic persons who come to the physician's attention show anxiety, in addition to the other neurotic phenomena. A difficult therapeutic dilemma not infrequently arises therefrom, which perplexes even the most experienced physician—whether to be content with efforts to assuage the anxiety or to try, more ambitiously, to help the patient toward a more radical readjustment. If the patient cannot endure much anxiety, attempts at a radical readjustment are likely to be defeated. PERSONALITY TRENDS

Habitual Responses to Conflict and Anxiety.—All persons, in the process of developing personality, have found and acquired certain aptitudes for dealing with anxiety-producing situations and persons, and these habits are the expressions of attitudes and sentiments which may be called personality trends. The regularity and adequacy of these trends determine largely the effectiveness and satisfaction in a personal adjustment to life. Abnormal personality trends have received more study than normal trends; yet this contrast is not so great as one might think because of the fact that the abnormal trend is often but an exaggerated or unbalanced expression of the normal one. Such considerations, unnecessary perhaps in dealing with relatively simple reactions to real and immediate situations, become of paramount importance in the more serious neurotic and psychotic reaction patterns. As has previously been indicated, a given patient's illness may represent in large measure the development of an automatic defense mechanism out of a personality trend, by which he gains consolation at the price of moderate distress or disability and thus saves himself from an intolerable anxiety or tension. In interviews with the patient, it is a good habit to scrutinize his behavior and his productions for light on two closely related questions:

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"To what anxiety is the patient's illness a kind of answer?" and "By what means has the patient in the past met this anxiety problem?" Such information is extremely important for therapeutic strategy, for therapeutic efforts can then be intelligently aimed at finding the means whereby the patient can obtain the relief and gratification he needs without resorting to neurotic or psychotic reactions. Why does not one always get this information simply by asking the patient what his anxieties are and how his illness affects them? One may get some interesting and valuable statements in this way, but one cannot rely on a neurotic or psychotic patient's direct answer to such a question to provide the necessary depth of understanding. So far as the patient's neurotic or psychotic forms of adjustment have alleviated his anxiety, to that extent he becomes unaware of it; consequently, the more neurotic or psychotic he is, the less he may realize that he has been solving his anxiety in that way, or even that he has had any anxiety. Furthermore, it is doubtful whether the patient is emotionally prepared to face clearly and appreciate fully the nature of the anxiety to which his symptoms constitute a defense; otherwise, he might not have needed to utilize that kind of an escape or defense. He will probably need to gain some emotional support from the physician before he can face it. This is another illustration of the principle that personality study is inextricably interwoven with therapy. Through considerable experience, psychiatrists have come to appreciate and respect the general fixity and persistence of personality trends and the necessity of recognizing them and taking them into account in management and therapy. The expression of these trends becomes extreme in psychotic and neurotic reactions; this extreme expression may be moderated, but the underlying trend is not likely to be extirpated from the organization of the personality. This persistence of personality trends can be considered fortunate for society in some ways, for such trends in mildly exaggerated form may constitute the foundation for personal careers of great social value. Mediocrity is not, after all, the ideal norm of personality. Society has, for example, much need for persons of obsessive trend, provided it is constructively applied. Sometimes the system of checks and balances by which a person has maintained a fairly consistent character in relation to others may undergo what seems to be a revolution, with the expression of new and different attitudes and traits. Organic disease of the brain may precipitate such an alteration of personality. A mood disorder may also do it. Such a change is most noticeable when it is disagreeable to others. There may thus appear a meaner or more profligate aspect

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of the personality, which has previously been kept in check. To one who is interested in the intricacies of human nature, there is a certain fascination in tracing back the hitherto undercover existence of such trends and in working out the manner in which the previous balance had been maintained; but this is a task of considerable delicacy, which can at times create more trouble than it does good. The commencement of training in personality study with patients in psychotic states offers an advantage in that such patients may exhibit these personality trends in such an excessive, caricatured fashion as to be obvious. A corresponding disadvantage may arise if the student comes then to recognize personality trends only when they occur in extreme form, for the chief value to the medical man of an understanding of personality trends is the insight afforded thereby into the adaptive limitations and possibilities (for good or ill) of all sorts and conditions of people who might become patients. Sentiments.—For the gaining of insight into the personality trends of the patient and their relationship to his interpersonal issues, a fruitful field of study lies in a consideration of his sentiments or prejudices, that is, his attitudes toward father, mother, siblings, and other significant persons, toward church and state, toward his home town and toward secret societies, anti-Semitism, socialism, fascism, and other isms. In the discussion of such matters, the patient reveals more clearly than in response to direct questions the character of his ideals and the way in which he has come to dramatize his role in life. Probably the most significant revelations are in the expression of his wit and humor, rather than in the more formal verbalization of his sentiments. In an attempt at reconstruction of the development of the patient's sentiments, his earliest years repay close study. It may be said that the sentiments of the adult are the sediments of his childhood. In studying the patient's past history and his own statements for information about his sentiments and prejudices, the physician should not neglect the information gained in nurses' notes and in casual observation of the patient's social behavior in the hospital situation. In dealings with hospital patients there is a tendency to look on all behavior as merely "symptomatic" of this, that, or the other type of disease and therefore to neglect its personal significance. Helpful insight into the patient's attitudes can be gained from the study of the manner in which he establishes relationships with other patients and with the hospital personnel. The patient's dramatization of the hospital situation often recapitulates the family situation of childhood. Two examples may be cited.

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A young woman used to lie rigid in bed, yelling or muttering the same phrase over and over: "You people, we people; you people, we people." This went on day after day, with almost unvarying regularity, for about two weeks. As she grew more mobile, further developments and remarks made it plain that she was acting out in a confused and exaggerated way the tensions and antagonisms of her childhood home. She had an Irish Catholic father and a mother of old New England stock—"we people; you people." A manic woman aged twenty-one used to make fun of her doctor, who was rather stout, dignified, and patronizingly tolerant. She teased him about sex and religion. When he came to the ward, she would yell out, "Here comes the bishop. He's got a 'hard' on today." She had been a rebellious, delinquent daughter of a rigidly moralistic missionary, who had fathered fourteen children. Need for Formulation of Personality Problems and Trends.—All of the sources of information which have been under consideration yield data for the case record, but the material needs to be formulated in order to yield a useful insight into the patient's inner conflicts and their possible solution or alleviation. If the patient remains under continued treatment and study, it is well to reformulate the patient's situation and problem from time to time after more knowledge has been gained and some of the inevitably false information has been straightened out. Repeated interviews bring decided advantages in personality study. A period of reflection should be systematically scheduled after every interview. The subsequent interview then gives one a chance to confirm or disprove or modify one's tentative formulations. A day's pause may also bring about revealing changes in the person studied. He may be found in a different mood. His "second thoughts" may bring out more significant information. He may have gained some needed self-respect or courage from the first interview, and with that support he may open up on matters previously concealed or "forgotten." The data of the medical history, the physical and neurologic examinations, and the special psychometric and laboratory tests must also be evaluated in order to arrive at a sound formulation. In the following section, additional suggestions are offered for recognition and formulation of problems and trends concerned with the personality. These suggestions are offered not as a system of explanations but as conceptual aids to the interviewer in getting a grasp of the biographic and descriptive facts and in organizing them into an

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understandable pattern. When this has been well done, the facts will tell their own story with a minimum of psychiatric "patter." Relation of Personality Trends to Interpersonal Issues When the material concerned with the patient's conflicts and personality trends is reviewed, it will frequently be noted that it has a close relation to certain interpersonal issues which can be discerned in the data on the patient's personal history and social adjustment. It can be stated, as a first approximation to the truth, that a person's personal conflicts arise from interpersonal issues between himself and others and that his outstanding personality trend represents the habitual way in which he has come to resolve some interpersonal issue. For example, some of the issues, conflicts, and trends concerned with the need for affection may be considered. Affection from the parents, or some equivalent thereof which leads to the care of the young, is a basic biologic feature of life in the higher mammals. The need for the parent's affection is the young child's most fundamental incentive to domestication and social conformity. In later childhood, another important incentive to social conformity comes from the desire for the respect of his fellows. Opposing these incentives to conformity is a strong human desire for independence and resentment of control, which reaches a peak in adolescence. A variety of interpersonal issues and personal conflicts may develop out of these contrary desires. When the affectionate response of parents or other loved persons is felt to be inadequate, insecurity and anxiety result. Almost every one reacts at some time to such apparent neglect by behavior which gains attention, even though it has to be misbehavior. Such attention-seeking tendencies are a common means of fulfilling a definite childhood need; yet they commonly evoke punishment or threats. When punishment leads to resentment, there is a conflict between the resentment and the desire for affection. Some persons succeed, in the main, in stabilizing this conflict by an attitude of extreme filial devotion, which serves, rather automatically, to assure affection and security ; but such a solution may be hindered or blocked by resentment. The frustrations of some of the child's natural propensities during the processes of domestication and socialization may also set up conflicts. In general, the desire for the feeling of security afforded by affectionate relationships more than balances these antagonistic impulses. It is important to recognize, however, that the usual course of life regularly leads to the development of certain areas of conflict. The fact that such conflicts do not remain sharply in the foreground of conscious attention does not mean that the conflicting feelings and

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impulses have no meaning for the behavior. In a fashion somewhat analogous to that which somehow maintains a "conditioned reflex," the organism maintains unconsciously many patterns of meaning, focused on certain significant persons, and these complexes of meaning frequently include conflicting tendencies. Personality trends develop as systematic ways of dealing with the anxiety generated by such conflicts. OBSESSIVE T R E N D . Resentful and aggressive impulses against persons on whom one is dependent for security form a prolific source of anxiety, experienced as a sense of guilt. Substitutive types of "goodness" may be developed, their degree of compulsion roughly approximating the degree of guilty anxiety arising from the unacknowledged resentment. Uncalled-for gestures of appeasement or perfectionistic rituals are the more obvious types of "making up for" such guilt or anxiety. This is the line of response which is developed into the obsessive trend. Such an obsessive trend may include excessive orderliness; meticulousness; exaggerated need for cleanliness, precision, or pedantry ; perfectionistic strivings; perseverative tendencies; ruminations; a habit of harping on subjects; hair-splitting argumentativeness; adherence to timetable routine in living; and extreme dependence on rituals. In the psychoanalytic school of thought, such obsessive developments are presumed to be derived from anal erotism and the formation of reactions thereto. Persons who show such obsessions are then called "anal characters." These statements are not so fantastic as they may appear at first blush. The housebreaking of infants is an early and important issue for the interaction with parental praise or punishment to which the obsessive trend may be one person's type of response. Even with a well-developed trend in the obsessive direction, certain persons may find such a solution inadequate to resolve their conflicts and then may suffer from anxiety attacks, or the undercurrent of resentment may break out spasmodically into the overt expression of defiance (the episodic expression of a self-assertive trend). HYPOCHONDRIACAL T R E N D . Other persons may be inclined to solicit the much desired affection through illness and so, quite without planning or intending it, may come to behave automatically in ways which might gain sympathy. Periods of convalescence from the illnesses of childhood provide early opportunities for the cultivation of this tendency. Sympathy, like attention, is an almost satisfactory substitute for affection. A well-established habit in this line shows itself most characteristically in the automatic magnification of trifling pain

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or distress and a great interest in the body functions. This is called the hypochondriacal trend. This trend may be greatly strengthened by an oversolicitous mother, especially when the mother's oversolicitousness represents an obsessive trend to make up for some hostility within her. For the person starting to cultivate a hypochondriacal trend, a fertile source of further preoccupation with bodily complaints lies in the physiologic expressions of his anxiety, such as unsteadiness of the heart rate, pronounced motor or secretory activity or inactivity of other viscera, aches in the head, neck, or back resulting from the muscular tension of the anxious state, or the conversion of mild itching into severe excoriations by frequent scratching. NEURASTHENIC TREND. A closely related trend, which also often shows itself in neurotic illnesses, is the tendency to anticipate frustration or failure by magnifying the difficulties which would excuse failure. If a person has had to gain acceptance by performance, that is, if he has not been able to feel that he is accepted with affection, on a personal basis, then any lack of success or the expectation of falling short of what would be considered worth while may be so great a threat to his security as to generate excessive anxiety, unless some excuse, like fatigue, can be manifested. Persons who are driven by a sense of duty rather than by enthusiasm are especially prone to magnify fatigue. The clinical picture called neurasthenia is so common a manifestation of this trend that it may be spoken of as the neurasthenic trend. Neurasthenic trends often accompany obsessive trends, serving to relieve somewhat the excessive sense of duty. Not infrequently, in investigation of the family background of persons with obsessive trends who work themselves into neurasthenic states, it will be found that there is a close relative rather strikingly deficient in a sense of duty, for whom the patient is unconsciously striving to set an example of "determination." "CONSTITUTIONAL INADEQUACY." There is a large number of persons with vague and ill-defined distresses and pains who seek vainly for relief, going from doctor to doctor and from one ill-advised operation to another. A good proportion of them would be much better off if they could acknowledge their limited endurance and live within their means, physiologically speaking. Alvarez has proposed the term "constitutional inadequacy," which is probably a useful description so far as it emphasizes the generalized nature of the disorder and the improbability of explaining it by reference to a specific organ and the impossibility of curing it by a specific ectomy or specific medi-

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cation. The constitutional designation, so far as it implies a hereditary cause, is somewhat too sweeping in its neglect of the personal, experientially determined aspects and the possibility, in some instances, of much relief and increased effectiveness through emotional re-education. Some of these patients have obviously poor physical endowment; others may have less obvious physiologic limitations, but many, in addition, are effort-addicted persons who do not feel "right" unless they are pushing themselves beyond their margin of safety. Constrained by this obsessive trend, they sentence themselves to a miserable alternation between neurasthenic invalidism and what is for them obsessive overwork. At the times when they appear in hospitals or clinics, they customarily present a neurasthenic picture with hypochondriacal features, but the obsessive trend constitutes the major difficulty in psychiatric treatment. ADDICTION. An escape from anxiety and guilt is made possible momentarily by the use of alcohol, ether, opiates, barbiturates, cocaine, cannabis, or other narcotic substances. Indulgence in such a method of escape through partial narcosis may become a firmly established reaction pattern, comparable to other neurotic habits of evasion and requiring similar study and treatment. PARANOID TREND. A decidedly different solution of the guilty anxiety over certain issues is found in the paranoid trend—the tendency to attribute hostile or aggressive motives to others. The "content" of a paranoid trend—the particular motives and intentions attributed to others—may mirror the patient's own inclinations. Some persons have not achieved an adequate perspective about themselves. They are lacking in insight and humor and cannot endure to admit the existence in themselves of some of the "baser" inclinations and propensities of human nature. If, for example, in the company of another person they become aware of improper sexual feelings—especially "perverted" or "inverted" inclinations—they may attribute this experience to a "base influence" of the other person, or even deny their own emotional responsiveness and try to dispose of the whole matter by attributing "designs" to the other person. In the degree to which it is successful, the paranoid trend relieves the patient's own anxiety over guilt by his blaming the other fellow. The reaction is somewhat analogous to the political device by which a nation may allay domestic discord and avoid civil war by a "defensive" foreign war. Persons who have felt a great need for affection and who are therefore sensitive when others do not live up to their heavy demand in this

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regard, are particularly prone to feel slighted and readily acquire paranoid tendencies. Other trends influence the paranoid trend. The hypochondriacal trend—preoccupation with symptoms and signs of illness in oneself— may supply the patient with ideas of being poisoned or otherwise injured in body by the persecutor. An obsessive trend of the perfectionistic type, when combined with the paranoid trend, may incline him to suspect that the persecutors are accusing him of wrongdoing— "They are spreading lies about me." The paranoid tendency to put the blame on others has a parallel in the tendency to self-magnification. In psychotic states the combined tendency is often expressed in combined delusions of persecution and of grandeur. TENDENCY TO DAYDREAMING AND DELUSIONAL AND HALLUCINATORY PREOCCUPATIONS. In a mildly pathologic way, consolation for

unsatisfactory relationships in real life may be found in daydreaming and in self-flattering delusions. In a healthy and constructive way, some kinds of imaginative playing with mere possibilities may be a useful and valuable offset to the obsessively realistic preoccupation with the actual. Scientific discoveries, inventions, and social vision come about through dissatisfaction with things as they are and the use of creative imagination as to how things might be different. Such trends, however, may take an unhealthy turn. When the sense of responsibility is slight or the incentive to conformity is weakened, there may be little to recall one to that regular habit of comparison with the consensus of the group which constitutes "reality" in the practical sense; and one may then remain seriously disabled for practical life through a delusional and hallucinatory preoccupation with nonpractical issues. It is surprising that only a few people are grossly and persistently deluded, for human beings quite regularly react, without much logical reflection, in ways determined by habit, sentiment, and momentary desire and then tend to rationalize their behavior by believing that which justifies such reaction. The fact that gross delusions are uncommon is attributed, in large part, to the strong human tendency to conform to generally accepted premises and obligations and in part to the capacity for plausible juggling of accepted premises into line with behavior which may be some distance out of line. The tendency toward delusional consolations does not ordinarily succeed promptly in gaining a gratifying delusional escape from "reality." Internal conflict and internal debate, with hallucinatory representations of the issues involved, may be prolonged and relatively

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unpleasant. Not every hallucinatory experience is by any means a direct wish fulfilment; many hallucinations are insulting and antagonistic, representing "the other side" of a personal issue. These varied tendencies toward fantastic daydreaming, hallucinatory preoccupations, and beliefs which are at variance with the practical consensus of one's fellows may be usefully designated by the term "delusional trend." The question whether, in a given person, such a delusional trend comes into prominent expression is determined not so much by the special force of this tendency as by the failure in those integrative forces which hold the person in order. In delirious and confusional states resulting from infection or exhaustion, delusional trends often appear. In the absence of confusion, pronounced delusional manifestations may ordinarily be taken to mean that there is a serious distortion of the personality, as with schizophrenic disorders. The delusional trend is, therefore, scarcely to be considered as a primary force in development of personality. It is, rather, a secondary influence, the clinical importance of which consists in shaping the clinical picture of a disorganized person. The glimpses into the patient's personal preoccupations vouchsafed by delusional statements may, however, have great importance, as do dreams and other fantasy productions, in revealing to the physician significant aspects of the patient's personal problems. DISSOCIATIVE T R E N D . Adolescent conflicts about sex are sometimes "solved" by the extraordinary dodge of losing a function. One may lose one's voice or one's hearing or sight; one may become paralyzed in the left leg or anesthetic on the right arm up to the edge of the sleeve, or one may "forget" certain matters. The falling away or separation of such a particular ability from the control or use of the patient without some organic lesion to explain it is attributed to a mental reaction called dissociation. This is the essential feature of what in modern times is called hysteria. The tendency to resolve conflicts by resorting unconsciously to such losses may be called a dissociative trend. When, for example, one feels sex as degrading or disgusting, yet is thrilled and incited toward mating behavior, a possible mode of defense against such an anxiety-producing conflict lies in the rejection of sensation in those parts whence thrills have come or in the rejection of power over those members the activity of which brought thrills. When avenues of incoming erotic stimulation or of outgoing adventurous search for such stimulation are blocked, one is immured in an ivory cage of "purity" and yet gets a derivative ascetic or saintly gratification. This trend, being in large measure a reflec-

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tion of current ideas of "purity," is subject to wide changes in fashion and subtle transformations. Sex is not the only source of shame which can serve as incentive to hysterical dissociation. Sensory and paralytic disabilities brought about by dissociation have been observed in military life, as automatic mechanisms for avoidance of what might otherwise be a dreadful disgrace. Memory dissociation, in the form of "fugue" or "amnesia," has also provided escape, in some instances from financial disgrace. ORGAN NEUROSES AND "PSYCHOSOMATIC" CONDITIONS. In these disorders a particular reaction of an organ or a system has become for the individual patient the expressive outlet of a particular personality conflict. Colitis, asthma, or dermatitis, for example, may become involved in such a personality reaction. Early experiences of physical illness at times of interpersonal conflict may "condition" these patterns of organic reaction so that they serve as the regular response to later similar conflicts. Repetitive patterns of disturbance of the activities of organs and tissues concerned in anxiety reactions may be important influences in the pathogenesis of indisputable organic disease, such as peptic ulcer or coronary sclerosis, or other conditions, such as hypertension, hyperthyroidism, cardiac decompensation, or arthritis. T H E "DON'T M I N D " TREND. One of the most seriously disabling trends is difficult to put into words. One habit of self-defense against the anxiety over lack of affection may be expressed in the words, "Nobody cares for me; well, I don't mind; I don't care for anybody else." When actually expressed in words, this reaction may not be so disastrous as when it is kept at a deeper level. With the more outspoken expression of resentments, such a personality development may be in the direction of trouble-making delinquency. With greater success in "not caring," the patient may make a schizophrenic adjustment to life. "Don't mind," translated into Latin, suggests "dementia," and "don't mind," translated into life, also comes out as something very like "dementia." CONSTRUCTIVE TRENDS AND THE INTEGRATIVE FORCES OF PERSONALITY. The preceding discussion of personality trends com-

monly encountered in clinical work leans heavily toward the pathologic. But picking a man to pieces in search of abnormal trends is an inadequate sort of personality study. The purpose of interviewing, and of the clinical study of personality, is a constructive and integrated grasp of the person as a going concern—not merely a delineation of

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the pathologic features, but an appreciation and evaluation of the assets and the constructive uses of even second-rate patterns of reaction. To speak figuratively, as well as literally, limping may be "caused," so to speak, by the deficiency of certain muscles the innervation of which has been destroyed, for instance, by poliomyelitis; but it is not the injured muscle which limps—it is the man, managing somehow to keep going despite the defect. Study should be aimed at finding, and therapy should be aimed at helping him use, whatever means may aid the man to do better. PERSPECTIVE ON PERSONALITY, SITUATION, AND REACTION.

In

a recapitulation of these suggestions for interview and personality study, a certain progression will be noted. Starting with a consideration of the presenting problem, the examiner notes primarily the patient's attitude toward this problem and the persons and responsibilities involved in the situation. Next, he gathers evidence about the conflicts which generate anxiety in the patient and about the personality trends by which the patient has come to react, customarily or episodically, to his particular conflicts. Then the examiner seeks information about the interpersonal issues in life about which these personality trends have developed. The length to which such a study should be pushed in the individual case depends on a number of considerations. As was stated earlier in this guide, some patients may manage very well to establish more order, peace, and security in their personal life with only simple enlightenment. Much depends, also, on the understanding and personal qualities of persons who are nearest the patient in the home situation. In cases of great complexity, the patient may need a great deal of help in getting a better perspective on the three main features of his problem: ( a ) his personality, (b) his reactions, and (c) the situation to which these reactions occur. There is often much confusion about these features. Commonly, the patient who is reacting with the physiologic expressions of anxiety thinks that these constitute his illness and does not understand that the essential difficulty arises from some incompatibility of his attitudes or from habitual reaction patterns which render him ineffective in settling certain personal issues. Perhaps the greatest difficulties arise in the misunderstanding of situations. Life situations are not adequately defined by the circumstances. Circumstances are merely the raw materials out of which people shape up situations, automatically, in terms of their personality organization. The issues are shaped by attitudes as much as by so-called facts. Nor does the physician understand ade-

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quately the theme of the patient's life situation until he recognizes and evaluates the attitudes which determine the issues involved.

Definitions and Terms Related to Personality SOCIAL DEFINITION OF PERSONALITY

Up to this point no definition of personality has been offered. There is, of course, much greater practical value in knowing how to deal with personality in action than there is in expressing the meaning of it in words. The usual definitions are somewhat too broad to be useful. Warren and Carmichael (5) stated: "Personality is the entire organization of a human being at any stage of his development." Menninger (3) defined it thus: Personality is the individual as a whole, his height and weight and loves and hates and blood pressure and reflexes; his smiles and hopes and bowed legs and enlarged tonsils. It means all that anyone is and all that he is trying to become.

The narrowness of the following definition (its restriction to the social significance of personality) may have a certain advantage of tangibility and definiteness: Personality is the organized system of sentiments or attitudes by which one establishes relationships with others and negotiates interpersonal transactions. In further elaboration of this definition, it may be added that one's sentiments are one's modes of emotional response to and expectation from others, as developed and fixed through interpersonal experiences; that the particular sentiments already established at a given stage of one's personal history set the patterns by which other persons then are accepted into significantly personal relationship; and that sentiments are relatively resistant to reasoning but are somewhat modifiable even late in-life, through emotional experiences in personal relationships. The quick appeal which one's personality has for others is largely determined 0

• •

100

90

do

80 70 60 50 40 30 20 10

15

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30

60

45

60

30

45

60 70 60 50 40 30 20 10 0 60

TIME IN MINUTES

xJi_HHYPER ACTIVITY

NORMAL ACTIVITY

HYPO ACTIVITY

FIG. 28. Correlation of color of gastric mucosa with gastric acidity-motor activity.

00-

-COLOP Of MUCOSA

TASTING AMD DISCUSSION OF TOOD

_

20

TKCINMINUTCS

FIG. 29. Changes in gastric function accompanying appetite. The frequency, height, and duration of gastric contractions is represented schematically on the lower part of the graph.

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Observations It was found that, in general, hyperemia of the gastric mucous membrane was associated with both increase in acid production and increase in motor activity, while pallor of the membrane was accompanied by a diminution in these two functions (Figure 28). Appetite.—Separate from the painful sensory experience of hunger, but regularly associated with it, is the emotion or feeling state called appetite. The awareness of a pleasant relationship to food is one of a group of situations which give rise alike to emotional variations and variations in gastric function. In Figure 29 are shown the changes in gastric function which were found to occur when the subject of appetizing food was discussed or when such food was tasted. Fear.—The "sinking feeling" in the stomach which accompanies fear is another familiar psychosomatic phenomenon. Intense fear is often accompanied by nausea. Figure 30 illustrates a situation in which sudden fear occurred one morning during the control period of accelerated gastric function when an irate doctor, a member of the staff, suddenly entered the room, began hastily opening drawers, looking on shelves and swearing to himself. He was looking for protocols to which he attached great importance. Our subject, who tidies up the laboratory, had mislaid them the previous afternoon, and he was fearful of detection and of losing his precious job. He remained silent and motionless and his face became pallid. The mucous membrane of his stomach also blanched from 90 to 20 on the color scale and remained so for five minutes until the doctor had located the objects of his search and left the room. Then the gastric mucosa gradually resumed its former color. Dejection.—Other emotions besides fear which imply a feeling of being overwhelmed and defeated, such as, for example, sadness and dejection, may be accompanied by anorexia, "sinking in the stomach," and nausea. Such a circumstance is illustrated by another disturbing event which occurred in Tom's life, namely, the death of his favorite nephew, the son of his most beloved sister. Tom's main affect was one of dejection. He didn't want to face the event. The same day his youngest step-grandson became ill with mumps. The following niorning, during the experimental period, Tom said, "I don't relish much going down there tonight" (the house of his sister). "I don't mind the funeral—but the wake! I told my wife somebody should stay with the grandson who got mumps, so I figured that she and

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my daughter could do down to my sister's and when they had enough, I could go down later. It doesn't matter how late I get home." Tom was noticeably pale and looked a little haggard, although he made an attempt at gaiety and buoyancy. He had no appetite. "I just feel funny—full. I don't want to eat." After the acceleration of gastric secretion induced by his breakfast had worn off, there was no free acid, and there were only approximately ten units of total acid. During the last three collection periods, the amount of juice obtained was too small for titration. Only 40 cc. of saliva was produced in two and a half hours, less than two-thirds the usual amount. t00% REDNESS. 90. 60_

o a a , , ^ , ^ ^ , ^ , ^ ^ ,

COtOR OF MUCOSA

70.

60. 5O_ 40_ 50. 20_ SUDDEN

HCt SECRETION

30

60 TIME IN MINUTES

90

120

FIG. 30. Changes associated with fear.

Comment Gastric hypofunction accompanying fear or dejection was regularly associated with a diminution in the flow of saliva as well as of gastric juice. When, in a setting of disgust or guilt with feelings of rejection, there occurred nausea in association with pallor, inactivity,

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and diminished acid secretion in the stomach, an accompanying increase in salivary flow as well as an apparent acceleration of secretion of gastric mucus was observed. The line of demarcation between these two types of gastric hypofunction is not entirely clear, except as indicated by the presence or absence of nausea. As has been shown elsewhere (11), nausea, however induced, is associated with absence of contractile activity in the stomach, with diminished acid secretion but increased output of mucus. Sustained Gastric Hypofunction Gastric hypofunction was not included in Tom's habitual way of reacting to threats. Occasionally, however, when he felt thoroughly defeated or overwhelmed by a situation, he did display gastric hyposo 40

3 O

30

§ Ul



ui 20 K

10

ff*t* MMUQ MMUS AM.C

«MM» «MU2 MATS MAY 14 IUVH JUH.I8 AUS.M S£FT » SEPT.*

FIG. 31. A persistence of gastric anacidity for two months during overwhelming fear and dejection. Each column represents the weekly average of determinations of free acid made daily.

function for longer or shorter periods. On one occasion, this pattern was sustained for two months and associated with anorexia, taciturnity, and loss of drive and weight (twelve pounds). One set of experiments, involving continued suction on an indwelling duodenal tube, was particularly distasteful and frightening to Tom. His fear and feeling of helplessness were accentuated when one day a technician, w whom he had never had full confidence, drew blood through the suction apparatus in the duodenum. As shown in Figure 31, Tom's

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stomach contained no free hydrochloric acid for ten months until a job was secured for the technician in another hospital. The day after she left, acid reappeared in the gastric samples. Appetite returned, and Tom again became his jovial, energetic, quick-moving self. Gastric Hypofunction and Disease Certain individuals seem to react to threats characteristically by a pattern of alarm and withdrawal, rather than fighting back. Such attitudes are associated with feelings of hopelessness and defeat. Illustrative of such a pattern is the case of a twenty-four-year-old single female, a stutterer who came to the New York Hospital complaining

PATIENT RELAXED AND DIVERTED

BEGIN

ALARM -DEJECTION - HOPELESSNESS

DISCUSSION OF ANTI-ZIONIST ADVERTISEMENT

NAUSEA

FIG. 32. Sudden interruption of gastric contractions followed by nausea upon experiencing feelings of alarm, dejection, and hopelessness.

of fullness in the epigastrium, associated with anorexia and nausea. She had been rejected by both parents, had reacted to life problems with indecision, and had attempted to resolve them by rationalization rather than by action. She felt that her own security and that of the Jews in general depended heavily upon the success of the Zionist movement. She was intubated with a gastric balloon and with another tube through which specimens of gastric juice were collected. The balloon was inflated in the stomach and connected to the kymograph. During a phase of gastric contractions of average frequency and amplitude, her attention was called to a newly formed society dedicated to opposing the Zionist movement and exposing what the

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society considered misrepresentations by the Zionists. She had not previously heard of the society, and she appeared horrified to learn of their activities. Pale and wide-eyed she stared at the examiner, immobile and obviously frightened. The motor activity in her stomach promptly stopped. The organ relaxed and increased in size. Finally nausea occurred. The gastric changes are illustrated graphically in Figure 32. Later discussion revealed that this individual characteristically reacted to threatening situations with anxiety in which there were strong feelings of hopelessness and despair. "When something comes up to worry me, I have a feeling of being defeated, that things are hopeless. That is how I felt when you showed me that advertisement of the anti-Zionist organization." Comment This type of gastric disturbance, seen commonly among soldiers in the horrifying anxious circumstances of combat ( 1 2 ) , was recognized several years ago by Walter Cannon ( 1 ) , and it was long thought to be the only way in which the stomach reacted during stress. In recent years, however, numerous workers have shown that as the face may blanch or blush in varying situations of stress, so may the stomach become either hypoactive or hyperactive, depending on the situation and the individual.

Gastric Hyperfunction, Anger, and Resentment Tom is a man of Irish extraction, small, wiry, energetic, conscientious, and friendly, but sensitive and easily offended, especially by slights to his proficiency and effectiveness as a worker, provider, or head of the family. He usually reacted to menacing situations by anger, resentment, and accelerated general activity, as well as with gastric hyperfunction. An example of the changes in motor activity and acid secretion which accompanied feelings of resentment and hostility occurred during an experimental period when a spontaneous phase of accelerated gastric activity had subsided an hour before and another would not be expected for at least one and one-half to two hours later. The parietal secretion and blood flow had not quite fallen to their control level, although contractions had decreased nearly to a minimum, with waves less than 1 cm. high on the recorded tracing. At this moment, a doctor for whom Tom had been engaged to do piecework housecleaning after hours entered the room. As he entered, Tom flushed

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a little, because he resented the past attitude of that doctor toward his work. The latter had insinuated that Tom's charges were excessive and that he worked too slowly. The doctor came to pay him off and tell him that his services were no longer required. Tom did not mind so much losing the work, but he was angry and hostile about the aspersions cast upon his abilities and conscientiousness. He felt humiliated and resentful. His face was red and his collar seemed too tight. The gastric mucosa became hyperemic and engorged and acid production was more than doubled. Vigorous contractions began, and his stomach presented an appearance of overactivity similar to but less marked than that encountered in experimentally induced gastritis (14). (See Figure 33.)

CONVERSATION EVOKNG FCELMGS OF HOSTUTY AND R£SCMTMENT

6ASTMC

MOTUTV

TftCMMMITCS

FIG. 33. Increased motility accompanying hyperemia and hyperacidity in association with hostility and resentment.

Sustained Resentment.—Tom's injuries were always either dealt with or relatively quickly forgotten, and never were gastric disturbances unduly sustained, except occasionally during periods of special stress as, for example, on an occasion when a certain benefactor on whom Tom depended partially for livelihood threatened to withdraw his support in view of Tom's decision to incorporate into his family the four children of his stepdaughter. Following the latter's death

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some months before, the children had been unhappily situated in an orphan home. Despite his benefactor's attitude, Tom persisted in his determination to undertake the additional responsibility of caring for the children. His reaction to this threat to his security was characterized by resentment at the interference with his personal affairs and seeming discrimination against him and anxiety about his economic welfare. During this period of stress, the average basal secretion of acid was significantly higher than during the preceding two weeks, and his membrane was continuously engorged and reddened. He was most eager to throw off his dependence on this person, and, two weeks later, when a new source of revenue became available in the form of increased pay from the hospital, he did so with great relief. Again his acid production and vascularity returned to former levels. The changes are illustrated in Figure 34. ACID SECRETION

COLOR OF MUCQSA

3*.

g ^ S i AVERAGE BASAL WM.UES DURING 2 WEEKS O F WtiaZk SUSTAINED ANXIETY I I

I AVERAGE BASAL VALUES DURING 2 WEEKS OF I CONTROL PERIODS BEFORE AND AFTER

FIG. 34, Sustained acceleration of gastric function during chronic emotional conflict.

Hazards of Sustained Mucosal Engorgement.—In the gastric mucosa of Tom, it was shown that sustained gastric hyperfunction gave rise to two potentially serious conditions in the lining of the organ, namely, a lowering pain threshold and an increase in fragility.

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Ordinarily, no pain was felt when noxious stimuli such as pinching or faradic current were applied to the gastric mucosa. Likewise, under average circumstances, the mucosa was impervious to blows from a blunt glass rod or to other minor traumata. Under circumstances of sustained engorgement, however, pinching and the application of faradic current were painful, and erosions and hemorrhagic spots resulted from minor traumata. Figure 35 illustrates one way 7 0 COLOR OF MUCOSA

GASTRIC JUICE APPLIED TO MUCOSAL EROSION

4 _ 3_ 2_

TIME IN MINUTES

FIG. 35. The acceleration of acid production following contact of gastric juice with an eroded mucosa.

in which a potential hazard from this situation was shown to exist. Two small hemorrhagic lesions were kept in contact with gastric juice with a titratable total acid of 90 for half an hour. Mucus accumulated rapidly in the region, but it was removed at frequent intervals by suction through a small glass tube. The acid gastric juice was then reapplied to the bare mucosa. A sharp acceleration of acid and concomitant hyperemia of the whole stomach mucosa occurred and persisted for half an hour after the submersion of the hemorrhagic lesions was discontinued. Comment In this phenomenon may lie an explanation of the persistent hyperacidity regularly encountered in persons suffering from gastritis and peptic ulcer. The fact that the base of the ulcerated lesion which is

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constantly bathed in acid gastric juice effects a stimulation of acid secretion indicates that afferent impulses subserve this reflex without sensation resulting. It is likely, however, that pain would follow an adequate chemical stimulus ( 8 ) .

Experimental Production of Ulcer The most peripheral edge of the collar of mucosa which lay exposed on the abdominal wall lacked adequate protection owing to defective formation of mucus in this region. A small erosion which occurred on this peripheral edge was exposed continuously to the digestive action of gastric juice for four days. During the first twenty-four hours the denuded surface increased in size. It bled intermittently. At the end of four days it exhibited the typical punched-out appearance of chronic peptic ulcer, with well-defined edges and a granulating base. It measured approximately 4 mm. in diameter, 1 mm. in depth, and was growing rapidly (Figure 36). Traction or pressure on this lesion resulted in pain of a dull, gnawing character, which was localized in the region of the lesion itself. Throughout the four-day period, the whole mucosa was relatively engorged, and the rate of acid secretion was significantly elevated. At the end of four days, because of the hazard to the subject, it was felt that the experiment could not be allowed to continue. The ulcer and surrounding area were covered with a protective petrolatum dressing. Within three days, complete healing had taken place, leaving no trace of the lesion behind. Clinical Peptic Ulcer Patients with peptic ulcer habitually react to stress by intense and sustained gastric hyperfunction. An example of such a reaction is provided by a forty-four-year-old civil service employee who had complained of gnawing epigastric pain off and on for twenty-years. His father had been a gentle retiring person and his mother a matriarchal woman, intensely ambitious for her children. His two older brothers were able to adjust satisfactorily to this setting, the oldest by graduating from medical school, the second one by adopting a rebellious attitude and becoming a professional gambler instead of a lawyer, as his mother had wished. The patient felt the need to compensate for his brother's indifference, and took premedical work in college. He did poorly and tried engineering instead. After failing that, he abandoned college. In this setting he had his first symptoms

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of epigastric pain, and a duodenal ulcer was demonstrated by radiologic examination. He later obtained a civil service job as draftsman and became engaged to a warm, sympathetic girl. Symptoms disappeared during this interval until the girl died of rheumatic heart disease a few months later. The patient's mother also died at approximately the same time. Within a few months he married an authoritarian, cold, and financially ambitious woman. She disapproved of his social relationship with men friends, and eventually forced him to give up lodge activities, from which he derived great satisfaction. Shortly after his marriage, the patient's ulcer symptoms recurred, and they have remained chronic ever since. Several exacerbations and two episodes of hemorrhage have coincided with periods in which his wife seriously disparaged his competence as a man. The following experiment, shown graphically in Figure 37, illustrates the relevance of his conflicts concerning his wife to his gastric disturbance. Ten minutes after the end of a spontaneous period of vigorous gastric motor activity and during a period of almost complete absence of contractions, an interview was undertaken in which the patient was reminded that in contrast to the high regard in which he had been held by his lodge associates, his wife considered him inadequate as a provider, companion, and sexual partner. He became grim and tense, clenched his jaws frequently, and said, "It's been a fight all along and now I got no more fight left in me. I'm caught like a rat in a trap." Promptly, forceful gastric contractions began, and by the end of the interview a state of incomplete tetanus had been established. Acid secretion was also greatly enhanced, exceeding the level observed during the earlier period of spontaneously increased gastric function. By this time, the subject had begun to groan with pain. Shortly, thereafter, during attempts at reassurance and diversion, the evidences of gastric hyperfunction subsided and with them the symptoms. Mechanism of Gastric Hyperfunction The pathways whereby the impulses responsible for this type of gastric hyperfunction reach the stomach are unknown, but they have been suspected of lying in the vagus nerves. Confirmation for this notion derives from an experiment performed on one of the fistulous subjects, whose fistula was made prior to the performance of a surgical removal of a carcinoma of the esophagus (13). During the latter

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ttrs 303

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procedure, it was necessary to section the vagus nerves. Thus, direct observations were available on the stomach before and after vagotomy. On coming to the laboratory for the third experiment, and prior to vagotomy, a marked change in the appearance and manner of the subject was noted. Earlier he had behaved in a quiet, friendly manner. On this occasion his face was red, and he appeared somewhat exasperated and irritable. He complained of stiffness and back pain ever since the previous experiment, and confessed that he was angry at having come down to the laboratory again, in view of the apparent delay occasioned in his operation. The subject's stomach was examined and found to be much redder and more engorged than before, about 70 on the scale in contrast to the previous 50. Asked about his concern regarding his condition, he said that he was reminded of the first doctor whom he had consulted for difficulty in swallowing. The latter had focused his attention on the stomach, much to the annoyance of the patient. "He was so dumb. I told him it wasn't my stomach, because I knew I couldn't swallow right. He made me waste four weeks fooling around." On this occasion, there occurred much more spontaneous motor activity in the stomach than before. The mucous membrane was so turgid that the minor traumata incident to the instrumentation with the cystoscope caused bleeding. The subject's dominant mood during this interview was anger coupled with hostility and strong feelings of frustration. His stomach displayed the picture of hyperactivity so characteristically found in the subject, Tom, during situational conflicts productive of aggressive attitudes. Approximately three weeks following vagotomy, an opportunity was afforded to repeat these observations under similar circumstances. On the third experimental occasion following vagotomy, the membrane was pale, 40, and the folds appeared especially thin. After the baseline observations, an attempt was made, as before, to induce anger and resentment in the subject by discussion of the doctor who had failed to diagnose his condition when he first consulted him. As on the occasion prior to vagotomy, he appeared to become significantly angered, with flushing of the face, loud voice, and aggressive gestures. "I think he is crazy. I only went to him because he is around the corner. He said the lining was off my stomach and gave me some stuff that made me feel lousy . . . last winter I had some crushed toes. He messed them up, too. He's a God-damned quack, an exileHe charged me enough—$8.00 a treatment. I'll tell him off." During this outburst, the patient's stomach was continuously under observation through the cystoscope, but, despite the redness of his face,

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there occurred no detectable change in the appearance of his gastric mucosa (Figure 38). BEFORE VAOOTOMY

AFTER

VAGOTOMV

COLOR OF MUCOSA



70 60 50 40 30 20



1 I

• • l • •

l.l Ml Mil • 1 • 1 1 1 CONTROL OEJEC RESENTriON MENT



CONTROL AFTER CONTROL PESENTFOOO MENT

FIG. 38. Variations in color of the gastric mucosa under a variety of circumstances before and after vagotomy.

Comment Failure of the stomach to become engorged during such a state does not necessarily implicate the vagus as a route by which impulses responsible for gastric hyperfunction occurring in response to situational threats reach the stomach. The evidence is highly suggestive, however, especially when considered in company with the clinical results in the treatment of peptic ulcer by vagotomy.

Protective Mechanisms in the Stomach One biologic defense against the completion of the unsalutary chain of events which apparently predisposes to peptic ulcer is an inhibitory effect on gastric secretion of acid and a promotion of mucus secretion, which occurs in response to the introduction of strong acid mto the cavity of the stomach. This effect is illustrated graphically in Figure 39. When 20 cc. of 0.1 N hydrochloric acid was introduced into the stomach during a phase of moderately active secretion, it inhibited turther acid production and stimulated the elaboration of mucus, with the result that the acidity of the stomach contents was profoundly reduced. Introducing 20 cc. of 0.34AT hydrochloric acid into the stomach evoked an even more striking elaboration of mucus, which within fifteen minutes reduced by one-half the molar concentration of the acid. By thirty minutes, the gastric acidity had returned to its former level.

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- TOTAL ADO

.VOLUME OF GASTRIC JUICE

60 TIME

IN MINUTES

FIG. 39. Acceleration of mucous secretion and inhibition of parietal secretion in response to the introduction of strong acid into the cavity of the stomach.

The clinical occurrence of this phenomenon is shown in Figure 40. The same ulcerous patient described earlier was examined during a period of considerable conflict and troublesome epigastric pain a few days after his wife, with contempt for his earning power, took a job. During the first part of the experiment, not only was motor activity accelerated, but also acid values were high. After they had climbed to a peak, there was an obvious elaboration of mucus, associated with a decline in the titratable acid and apparently an actual decline in the production of hydrochloric acid (Figure 40). Modification of the Effect of Food The profound changes in gastric function which have been demonstrated to occur as part of an individual's reaction to problems and threats in his social setting may modify greatly the usually expected effects of differing diets on the gastric motor activity and emptying time. Such a phenomenon is shown graphically in Figure 41.

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At 6:30 A.M. the subject ate breakfast, which consisted of two eggs, scrambled in butter, one slice of buttered bread, one pint of milk, and five cups of weak coffee. At noon, five and a half hours later, the process of digestion was not completed, 300 cc. of greasy, very fluid, yellowish gruel, approximately 25 per cent of the bulk of the meal, being recovered. The stomach was not in a state of accelerated function. The color of the mucosa was 60, and titratable free acid of the undigested material was 4. The pattern of contractions was different from that recorded at any time in the fasting stomach. The waves came in groups of 3-5, the earliest waves in the group being small and each subsequent one higher, until they reached a size about one-fourth that of the usual recorded vigorous contraction. Occasionally there occurred a short period of quiescence, followed by a similar group of waves. A sample of this tracing is reproduced in Figure 41. AVERAGE FAT CONTAINING BREAKFAST

AVERAGE FAT CONTAINING BREAKFAST IN SETTING OF ANXIETY AND TENSION

AVERAGE BREAKFAST WITH FAT OMITTED

100%

a. 3

INGE:

_ > -• D. < 2U O2

a.

5

ACH ALMC ALL TRACI

S FOLLOWI

«

2* 2 i—i

ACID

4.75

-NO UI

ETEL'1 EM REM AINU

2 ts

ut

u.

AVU\ FIG. 41. Duration of gastric digestion under various circumstances. Motility pattern prevailing at the time the stomach was examined is represented in the lower frames.

As a rule, under circumstances of relative security and contentment, the average breakfast was emptied from the stomach in six hours.

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309

When the breakfast described above was eaten without butter or milk and with boiled eggs, the stomach was found to be entirely empty of food four and three-quarters hours after its ingestion. The organ was still intensely active, however, and the mucosa was hyperemic and engorged. Free acid was 88, and tall waves of contraction were occurring (Figure 41). When the breakfast detailed in the first experiment was eaten with 100 g. extra butter, 6 hours later 10 per cent of the meal still remained in the stomach. The mucosa was pale, 45-50, and free acid was 23. No contractions, except the familiar basal three-a-minute waves, were taking place. The average breakfast, which contained approximately 50 g. of fat, was ingested each morning during three weeks of emotional conflict involving anxiety and resentment. Tom was disturbed over his economic state, because of having loaned money unwisely to an irresponsible person, over an administrative delay in raising his pay from the hospital, the rising cost of wartime living, and the prospect of assuming new financial burdens with the support of his grandchildren. Throughout this period, his stomach was found to be emptied entirely of his breakfast in four to five hours, although under circumstances of relative contentment, complete emptying would not be expected for from five to six hours. Furthermore, despite the presence of fat in the meal, his mucosa was hyperemic, acid values were high, and motility was active. On one occasion in the midst of this period, he was entrusted with an errand which was obviously designed to test his eligibility for promotion to a more responsible job in the laboratory. He was intensely eager to discharge his responsibility creditably, and in his anxiety was overactive and overtalkative and perspired a good deal. His stomach was examined five hours after ingestion of breakfast. The stomach was empty. The mucosa was red (85), turgid, and engorged. Free acid was 104, and motility was unusually active (Figure 41). Modification of Effects of Drugs Concerning the introduction of drugs into the stomach, it is fair to generalize that vasoconstrictor substances give rise to a diminution m gastric function, while vasodilators cause hyperfunction in the stomach (16). Effects which accompany variations in the subject's emotional state were found to modify the pharmacologic action of

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various agents as they do the results of the adsorption of protein and fat. Benadryl—During a period of relative relaxation and security, when the gastric mucosa was comparatively pale and nonturgid and when the contractile activity was not more than average, 50 mg. of benadryl were introduced into the stomach. Within fifteen minutes, a perceptible pallor of the mucosa had occurred, associated with a diminution in turgidity and a corresponding decrease in acid output. There was a sharp acceleration of mucous secretion, however, as measured by the viscosity of the samples as well as by their mucin content ( Figure 42). This experiment was repeated when the gastric MUCIN 'ISCOSI T V

a •urea DI TY UNITS

-•MUCIN

O VISCOSITY

OCOLOR

•"O--—-O--0ACID O TURGID! T V

10

20

30

40

50 BO 70 60 TIME IN MINUTES

90

100

110

120 130 140

FIG. 42. Effect of benadryl during phase of average gastric function.

mucosa was relatively engorged and the stomach overactive in terms of acid secretion and motility during the period when Tom was experiencing feelings of special anxiety associated with hostility and resentment on the day following his stepgrandaughter's broken engagement. When benadryl was administered in these amounts during this prevailing state of gastric hyperactivity, it exerted no detectable effects (Figure 43). Intermediate results were obtained when benadryl was administered during moderate gastric hyperac-

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tivity following recent ingestion of a meal or during anxiety of a mild degree. MUCIM V.SCOS.TY TURCIOITT OMITS «

> ACID UNITS 120

ACID

o o

o

I

VISCOSITY

20 10

0

COLOR TURGIDITY

|8ENA0RYL 0 0 5 GM.

0 10

20

30

40

SO

60

70

80

90

100

110

120

130

140 ISO

TIME IN MINUTES

FIG. 43. Lack of effect following administration of benadryl during a phase of gastric hyperactivity related to situational stress.

Comment The administration of pyribenzamine and a posterior pituitary extract was followed by similar effects, namely, inhibition of gastric function when the stomach was in an average state of activity but no demonstrable effect when administered during a phase of gastric hyperfunction.

Urogastrone Urogastrone, like benadryl and the other drugs mentioned above, was capable of inducing gastric hypofunction when administered under suitable conditions of relaxation and security, but when administered during a period of sustained resentment associated with hyperer nia, hypermotility, and hyperacidity in the stomach, its effect was not recognizable. The contrast of findings is illustrated in Figure 44.

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DISPOSSESS NOTICE LAST NIGHT

X*COLOR 0 « ACID O'HCL TUR6I0ITY

IS

3O

45

«O

75

TIME IN MINUTES

00

105

120

0

15

30

45

60

75

00

105

120

TIME IN MINUTES

FIG. 44. Comparison of the effect of the gastric inhibitor urogastrone when administered during average circumstances and when the stomach was markedly hyperactive during anxiety and resentment following the receipt of a dispossess notice.

Szasz, Levin, Kirsner, and Palmer (10) have made similar observations in the case of enterogastrone. They found that this agent, which usually effected a decrease in gastric acidity, was ineffective when administered to an angry, resentful subject. Biologic Significance of Patterns of Disordered Gastric Function—Discussion It has been postulated elsewhere that the pattern of gastric hyperfunction, resembling as it does the state of the stomach during preparedness for food, may indicate a symbolic need for nourishment and sustenance at times of stress (6). The pattern of hypofunction without nausea may represent, as Cannon has suggested, part of a general biologic pattern of mobilization for action in which, during an emergency, the stomach and digestion can wait. When it is associated with nausea and vomiting, the pattern of gastric hypofunction seems to indicate a need for riddance, an effort

EMOTIONS AND GASTRIC FUNCTIONS

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to reject noxious experiences. Such a riddance pattern is often accompanied by diarrhea, and may also be associated with efforts at shutting out noxae, for example, with constriction of the esophagus, difficulty in swallowing, or refusal to eat. Often, however, instead of such an integrated pattern of rejection, fragments of the pattern existed by themselves. For example, certain patients displayed difficulty in bringing food to their mouths but no disturbance once it passed the teeth. Others ruminated the food and had difficulty in swallowing it, but had no disturbance once it was swallowed. Still others displayed only an esophageal disturbance, with delay in passage of the bolus from hypopharynx to stomach. The existence of such fragmentary manifestations of biologic patterns of defense may indicate ambivalence or inner conflicts with incomplete direction of drives. Summary and Conclusions It is clear from these data that there occur in the stomach disturbances of function in response to threatening situations and that these disturbances may give rise to troublesome symptoms. In general, these patterns of disturbance are characterized either by overfunctioning of the stomach or underfunctioning of the organ. The same individual may display either pattern under varying circumstances, but one type of response may be characteristic for a given individual because of conditioning by an earlier experience productive of that particular pattern. The degree of response in the stomach to stimuli arising out of situational stress was found to be great enough to modify or even cancel out the effects of the ingestion of various foods or drugs. Gastric hyperactivity was found to be frequently associated with heartburn and epigastric pain of a gnawing quality, characteristically more intense during periods when the stomach was empty and usually relieved by taking food, milk, or alkalies. Gastric hypoactivity, on the other hand, was found to be accompanied by feelings of fulness in the epigastrium and nausea. The principal difference between the emotional reactions accompanying gastric hyperfunction on the one hand and hypofunction on the other appears to be in whether or not the subject considers defeat at the hands of his adverse situation a "fait accompli." As Charles Darwin expressed it, "If we expect to suffer, we are anxious; if we have no hope of relief, we despair" (2). The individual whose stomach is hyperactive is physiologically prepared for food whether or not he has an appetite. He often feels angry in his need of being

314

CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY

fed or cared for, but he is accepting his position vis-a-vis his situational threat and is doing something about it, preparing for either fight or flight. The individual whose stomach is hypoactive is not accepting the challenge of the situational threat. His associated nausea expresses his distaste for the situation. Thus, life situations that give rise to anxiety and conflict may give rise to reactions that express the way in which the organism proposes to deal with the problem. It would be entirely appropriate for the gastrointestinal tract to participate in such a reaction, since it is concerned with expressing and dealing with an individual's most pressing needs for survival. REFERENCES 1. CANNON, W. B. The influence of emotional states on the functions of the alimentary canal. Amer. J. med. Set., 1909, 137, 480. 2. DARWIN, CHARLES. The expression of the emotions in man and animals. London : John Murray, 1872. 3. HOLLANDER, F. Studies in gastric secretion: III. Evidence in refutation of the Rosemann theory of hydrochloric acid formation. Amer. J. Physiol., 1931, 98, 551. 4. . Studies in gastric secretion: IV. Variations in the chlorine content of gastric juice and their significance. / . biol. Chem., 1932, 97, 585. 5. . Studies in gastric secretion: V. The composition of gastric juice as a function of its acidity. / . biol. Chem., 1934, 104, 33. 6. MITTELMANN, B., and WOLFF, H. G. Emotions and gastroduodenal functions. Psychosom. Med., 1942, 4, 5-61. 7. Munsell Book of Color. Baltimore: Munsell Color Co. 8. PALMER, W. L. Mechanism of pain in gastric and duodenal ulcer. Arch, intern. Med., 1927, 39, 109. 9. RICHARDS, C. H., WOLF, S., and WOLFF, H. G. The measurement and recording

of gastroduodenal blood flow in man by means of a thermal gradientometer. / . din. Invest, 1942, 21, 551. 10. SZASZ, T. S., LEVIN, E., KIRSNER, J. B., and PALMER, W. L. The role of hos-

11. 12. 13. 14. 15. 16.

tility in the pathogenesis of peptic ulcer: theoretical considerations with the report of a case. Psychosom. Med., 1947, 9, 331. WOLF, S. The relation of gastric function to nausea in man. / . clin. Invest., 1943, 22, 877. . Observations on the occurrence of nausea among combat soldiers. Gastroenterology, 1947, 8, 15. WOLF, S., and ANDRUS, W. D E W . The effect of vagotomy on gastric function. Gastroenterology, 1947, 8, 429. WOLF, S., and WOLFF, H. G The gastric mucosa, "gastritis and ulcer." Amer. J. digest. Dis., 1943, 10, 23. . Human gastric function (rev. ed.). New York: Oxford University Press, 1947. . Action of drugs and various chemical agents on the gastric mucosa and gastric function in man. New York J. Med., 1946, 46, 2509.

Chapter 14 LIFE STRESS AND BODILY DISEASE1 By HAROLD G. WOLFF,

M.D.

The Nature of Stress in Man MAN IS EXPOSED to assaults by other living forms that aim to invade as parasites or to destroy; by meteorological and climatic crises that pass sometimes predictably and often whimsically over the earth's surface; by other physical forces that operate upon man merely in terms of his mass and volume; and by elements of the earth's crust which man often dangerously manipulates for his comfort and delight or to fulfil his passion for destruction (90). But, constituted as he is, man is further vulnerable because he reacts not only to the actual existence of danger but to threats and symbols of danger experienced in his past which call forth reactions little different from those to the assault itself. Also, most important, he is a tribal or group creature with a long period of development and dependent for his very existence upon the aid, support, and encouragement of other men. He lives his life so much in contact with men and in such concern about their expectations of him that perhaps the greatest threat of all is his doubt about his ability to live the life of a man. He is threatened by those very forces in society upon which he is dependent for nourishment and life. He must be part of the tribe and yet he is driven to fulfil his own proclivities; because of his sensitive organization, he is often pulled two ways at the same time. These threats and conflicts are omnipresent, and they constitute a large portion of the stress to which man is exposed. Stress is the interaction between organism and external environment, and strain ^ the alteration or deformation in the organism that then ensues. The magnitude of the latter and the capacity of the organism to withstand strain determine whether or not there will be re-establishment of homeostasis or a "break." 1 More detailed data concerning the experiments upon which these inferences were drawn can be obtained from Life Stress and Bodily Disease, Volume XXIX ™, the 1949 Proceedings of the Association for Research in Nervous and Mental S ^ e Baltimore: The Williams & Wilkins Co., 1950). This article has been modified and expanded from chap, brix of this volume.

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The Biologic Significance of Bodily Changes During Stress From these considerations it seems clear that not only do forces or individuals that jeopardize the life or love of a human being constitute major threats, but so also do those which interfere with the realization of his aspirations and needs or block the exercise of his potential (88). These threats are reacted to by the mobilization of an individual's defenses. A considerable part of the human equipment has to do with meeting emergencies and dealing with crises. The patterns of reaction thus set in motion are adaptive and protective and are largely defensive or offensive depending upon the individual's nature, his past experience, and the situation (59, 67, 88). They are more or less effective and more or less costly to him depending on these and other factors, such as the nature and integrity of the structures participating in the protective reaction. Some of these reactions represent widespread mobilizations to provide extra fuel and energy for vital parts of the organism. Others appear to be focused on regional defenses, notably at portals of entry and exit. Offensive and defensive and general and local protective devices may operate together or separately. Along with these conspicuous bodily preparations go certain feelings and attitudes which, stemming from the same needs, have the same goals. The organism may sacrifice at such times some functions or capacities for the sake of promoting others more important in meeting the adverse situation. Although there is a degree of specialization in the sense that one or another protective arrangement is dominant, discrimination is not exact. In a threatened man, it is common to find a variety of protective reactions, some extremely pertinent, others less so, and still others minimally effective. Owing to training and cultural pressures, an individual develops a more or less fixed idea of how he is expected to appear, behave, react, and even feel about things. Because a man's drives are primitive and even violent, and out of keeping with his conception of what is expected of him, they may be unacceptable to him. Then, when his drive is denied (though not fully recognized by him), the subsequently evoked protective reaction patterns may unwittingly become sustained. Perhaps the most dramatic demonstration of the effects of environmental pressures and stresses on form and function are seen in the "domestication" of rats, so carefully investigated by Richter (59).

LIFE STRESS AND BODILY DISEASE

317

Outstanding are the reduction in size of the adrenals and thyroid and the increase in size of the pituitary glands; the augmented capacity to adjust to changes in food, to meet laboratory circumstances, including man, and to withstand stress without attacking neighboring animals; and the reduction in the capacity to tolerate poisons. Wild rats in captivity are loath to breed, and they even eat their young. Possibly only those capable of domestication reproduce in such circumstances. The degree to which such changes occur in one life span is as yet unmeasured. However, the investigations on man reported herewith show how radically form and function of structures may change during long-standing and sometimes amazingly brief periods of stress. When one asks why one organ rather than another is involved during stress, there is no complete answer, but pertinent facts will be considered below. More profitable perhaps is the question of how the organ is implicated in a biologic pattern of offense or defense (88). The repeated or prolonged participation of a given organ in a protective pattern cannot be construed as evidence of the weakness or inferiority of that organ, even though because of such participation it fails to maintain its structural integrity. The individual may be said to be weak or living under undue stress, but the organ can hardly be said to be weak, and indeed it may be especially well developed and strong.

Methods Regardless of preference as to detail and emphasis, data about the person to be studied have been obtained by appraisal of his behavior, both past and present, including his utterances about his experiences, fears, hopes and fantasies, either spontaneous or those in reaction to interjected life circumstances and test situations. In addition, an aspect of the function of one or another organ or system relevant to a symptom or disease and pertinent to the individual studied was concurrently analyzed, and when possible, correlations between the general behavior and the specific system function were made.2 2

A viewpoint held by several contributors to Life Stress and Bodily Disease was

expressed thus: "The methodology of physiologic and psychologic-psychopathologic investigations is essentially different. It is unlikely that one person can master both methods and develop a fertile imagination along both lines. A team of investigators is therefore desirable." The editor shares this viewpoint only to a limited degree. Jn his opinion it stems from a confusion between research of a basic, orientative nature, and development of such discovery. In the development of discoveries, teams are of great importance and carry the work ahead rapidly and effectively. In orientative investigation, men work alone or through a most intimate relation between two or three persons with whom fantasies and difficulties are shared. In short, it is when an investigator is able to embrace in his own creative fantasy the broad principles of biologic function and methods that major advances can be made.

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CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY

Some workers preferred and emphasized the significance of data derived from free association, dream analysis, and the relationship between the individual and the physician (1, 21, 28, 31, 37, 42, 45, 47, 51, 77). Others included such data but were more eclectic in their methods. The latter (2, 3, 4, 9, 11, 12, 13, 14, 15, 16, 17, 19, 20,22, 24,27, 29, 32, 35, 36, 38,40, 41, 43, 44,46, 49, 52, 55, 56, 58, 60, 61, 62, 64, 65, 71, 74, 75, 76, 78, 79, 85, 86, 87) collected facts about the life history of the individual in its cultural framework, exploring particularly the demands, values, standards, and actions of the parents, siblings, spouses, and "superiors." Through these figures they also explored the preferences and prejudices of the group with which the individual studied was or wished to be identified. Data were obtained from the subject's statements, from his appearance, dress, manner of speaking, gestures, and posture; from his reactions in the company of others, including the physician, authoritative figures, associates, competitors, and subordinates; from his dreams and associations and things said and left unsaid. Projection and word and picture association techniques were used and appraisal was made of the kind of relationship the patient attempted to establish with the physician. In studies of children, their play with toys was appraised. From these sources and from statements by friends or members of the family the trained observer attempted an assessment. Fluctuations in the course of the illness in question were then correlated with events, attitudes, emotions, and the behavior of the subject. When positive correlations with some conflict situation were evident, short-term experiments were carried out while indicators of the organ function were measured and recorded. After a suitable control period of relative relaxation and security, the subject matter of the suspected conflict was abruptly introduced into the interview. If significant changes were then observed in the measured functions at this time and not during discussions of other more neutral topics, and if these subsided when the subject was successfully reassured and diverted, it was inferred that the conflict and the bodily changes were linked. When under these circumstances a given topic precipitated a change in feeling and bodily function, it was inferred that such a constellation was relevant to the change, but not that the topic itself was of necessity the focus of the patient's conflict. However, it was assumed that the subject matter evoking the protective reaction was representative of the kind of situation and interpersonal relationship pertinent to his symptoms and bodily changes. By further detailed study it was then sometimes possible to establish which features were

LIFE STRESS AND BODILY DISEASE

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of basic dynamic significance to the patient (4, 13, 20, 24, 32, 35, 36, 44, 52, 56, 60, 64, 74, 75, 76, 79, 85, 86, 87). Confusion arises from the difficulty of defining satisfactorily the unconscious and from the question, "Can a person be feeling something without being aware of any feeling?" Although until recently the word "feeling" usually implied full awareness, just as the word "I" was identified with that portion of experience which enters consciousness, the meanings of the two words have gradually expanded. Now it is understood that but a minute fraction of the experience of an individual enters consciousness, and " I " is taken to be the resultant of a lifetime of situations, stimuli, and reactions, including those of which he is conscious as well as those of which he is unconscious. "Feeling" has come to mean a type of nervous system activity in reaction to stimuli, which may become manifest in consciousness but which operates widely regardless of awareness, together with its accompanying behavior and bodily reactions (23). Thus the term "resentful," for example, may be applied to an individual because he attests to feeling resentment or because of a dream, a slip of the tongue, or a spiteful act, despite persistent denial of a "feeling" of resentment. The two sets of circumstances are separated only by the contrasting degree of the subject's awareness. Margolin et cd. (45) on the basis of studies of a woman with a gastric stoma and Mirsky et al. (47), using pepsinogen excretion in urine as an indicator of gastric function, emphasize that only through a knowlege of unconscious processes can one interpret the changing patterns of the stomach. Implied also is the view that only through the application of special procedures and concepts is the true state of the unconscious revealed, and inversely that conflicts and feelings of which the subject is conscious are not relevant to or indeed are even misleading in attempts at the correlation of gastric function, life situations, and emotions. Observations made on the gastric mucosa of subject Tom (81, 86) support the view that the stress and conflict most significant or most threatening for the individual is the one most relevant to the changes in the stomach or indeed in any part of the organism, regardless of whether that conflict constellation be conscious or unconscious. Since important conflicts are more likely to be repressed into unconsciousness than less important ones, Margolin's and Mirsky's observations are often confirmed, but it would appear to be more profitable at this time to emphasize the basic significance of the situation to the individual rather than his degree of awareness.

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The subject under investigation acts as his own control, a fact of major importance. Groen and van der Valk (27) have made a study bearing on the topic of "control" as applied to the investigations. They have demonstrated that forced inactivity in the experimental setting may in itself produce profound effects on some patients. Pavlov (50) emphasized this to be important in certain dogs. Long delays between phases of stimulation, too often repeated stimuli, or protracted restraint in the experimental harness, made difficult the interpretation of the subsequent reaction to specific experimental stimuli. Scott (66), Liddell (39), and Gantt (19) have repeatedly confirmed these observations. It is a feature of the particular neural integration of man that changes in the central nervous system manifesting themselves as tension, boredom, or resentment may occur under circumstances that would be considered optimal for simpler types of biological experimentation. Also, repetitive presentation of a noxious stimulus may cause diminution in its effect for a longer or shorter period (4, 18). Conditioned stimuli of very high intensity or symbols of great importance may not lose their power to evoke reactions even though they are presented over a long period without reinforcement. However, symbols of less significance and constellations of experience or vocalized memories of lesser basic importance often rapidly lose their capacity to evoke bodily changes. A rapid decline of brain-wave responses to a given topic or stimulus when repeated has been noted in a wide variety of experiments with brain waves (4). The rate of decline varies with many factors. The decline of wave response with repetition of stimulus may be noted whether the stimulus is a suggestion given during hypnosis or a symptom-provoking life situation. If the stimulus or problem acquires deeper significance with each repetition, however, response may not diminish but may even become accentuated. The phenomenon of dwindling response was carefully analyzed by Hardy and Furer while changes in skin resistance in reaction to noxious stimulation were being recorded (18). It was shown that pain induced by thermal stimulation was associated with a fall in skin resistance of the palms during initial trials, but as the stimulus was repeatedly presented the response became more and more difficult to elicit, even though the intensity of pain experienced was unaltered. When the stimuli were sufficiently intense, however, such dwindling of effect did not occur. Also, if the stimuli which were producing no reaction were withheld for a week and then reapplied, they again called forth responses for a period of varying duration.

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321

Thus, in establishing "controls" or collecting data, the observer aimed to strike a balance so that validity through sufficiently long control periods and repetition of observation was not offset by errors from altered responses and mounting tension caused by prolonged inactivity or repetition. Protective Patterns of Offense Involving Eating —the Stomach and the Duodenum One of the earliest aggressive patterns manifesting itself in the infant is that associated with hunger and eating (81). This pattern may reassert itself in certain individuals in later life when they feel ACID

COLOR OF MUCOSA

3.0


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343

this deprivation aroused hostility, often focused upon the parent figure whose love they most desired. Their craving for love and support was therefore complicated by an inability to accept it. Even in their earliest infancy and childhood they reacted to such stresses as the illness of the mother, the birth of a sibling, or rejection by parents with an increase in appetite, increase in weight, and demand for sweets; the parents often remarked on this, saying, "He always ate more than the other children" or " H e was always asking for sweets, even from the time he was a little baby." Since in earliest infancy the relation between food and mother love is very close, security and love become associated with foodgetting throughout life, and the starvation pattern may be evoked in response to the absence of either food or love. The diabetic patient reacts as though food and security were identical and develops a physiological reaction appropriate to starvation at a time when he is exposed to deprivations other than those of food. In this same sense then, diabetes mellitus may be viewed as the inappropriate use of an adaptive reaction. For short periods such a response, though clumsy, might be harmless, but through long-continued use it is associated with the irreversible changes of function and structure characteristically found in diabetics. Life crises in the diabetic may evoke an exacerbation of the pattern of fat and ketone utilization leading to ketosis, coma, and death. Periods of sustained stress may be associated with changes in the regulation of body temperature. Thus Goodell, Graham, and Wolff (20) have been able to show that the amount and duration of elevation in body temperature in response to a given amount of work done is closely related to the existing feeling state. In general, a given amount of work produced a rise of body temperature sustained for a longer time during periods of sustained emotional tension and conflict than during periods of relative tranquillity. This observation gains interest in the light of the observations of Meyer Friedman ( 1 6 ) , who calls attention to the fact that patients with "functional heart disease" often exhibit hyperthermia with temperature elevations of 1-2 F. Moreover, in a few suggestive experiments he has shown that such patients in response to given amounts of typhoid vaccine given intravenously elevated their body temperature approximately * F., in contrast to a group of more relaxed persons in whom the elevation was about 1°F. lhere are many other adaptive and protective patterns involving basic metabolic processes, some exceedingly relevant to bodily disease

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(12, 14, 16, 28, 30, 33, 40, 51, 53, 55, 65). It is likely that the neural processes involved in conditioned reactions are operating in these behavior patterns, but at the moment it is more profitable to consider behavior in broad biologic terms. Any organ, system, or combination of systems may participate in either defensive or offensive patterns. These patterns become medically significant, as mentioned, when they are prolonged, since irreversible changes and tissue damage may ensue. The generalizations of Selye (67) concerning the adrenal gland and the adrenocorticotropic hormone of the pituitary, important though they be in illuminating aspects of many reactions to stress, and especially as they relate to involvement of the adrenal cortex, cannot be construed as a universal formulation. It is quite likely that, after initial adaptive adjustments involving adrenergic fibers of the autonomic nervous system, endocrine structures, notably the adrenal cortex, may dominate the resultant sustained adaptive reaction. But it appears that there are other adaptive responses—for instance, peptic ulceration involving cholinergic fibers in the vagus nerve, hyperdynamic response in the nose and colon involving cholinergic fibers and impulses to specific structures, and the discovery of acetylcholine-like bodies in the blood during periods of stress and unpleasant emotions (11). Important as the central integrative apparatus may be, it would seem unprofitable to view adaptive and protective reactions as primarily stemming from the operation of one part or one system. Ray and Console (57) and Scarff (63) have indicated how major neural structures may be disrupted without collapse in adaptation. On the other hand, serious incapacity on the part of the patient may occur when only minor structural changes are present. As noted in earlier studies on headache, many patients overreact to minor disturbances or sensations when their site takes on special meaning with regard to the integrity of the individual (89). For instance, past conditioning experiences may endow the nose with special significance, so that minor disturbances in nasal function have ominous implications for the individual. The processes of defense and offense may lead to disastrous results in the airways, stomach, large bowel, heart, blood vessels, kidneys, and other bodily structures (60, 87). Furthermore, the continuing effort to resolve emotional conflicts through the use of unsuitable protective and adaptive patterns may lead to the destruction of the individual. In brief, man, feeling threatened, may use for long-term purposes devices designed for short-term needs. Costly protective

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activities are essential and life-saving. They are devised for fleeting emergencies so that man may cope with those forces that threaten his survival. But they are not designed to be used as life patterns, and when so utilized they may damage structures and so destroy the organism they were devised to protect. The formulation of protective and adaptive reaction patterns here presented illuminates certain well-defined disease syndromes. It is evident, however, that some reaction patterns accompanying life experiences are not clarified by this concept. For instance, widespread bodily changes and symptoms occur in some individuals immediately following stress or emergency. Headache, vasomotor changes, vomiting, diarrhea and other gastrointestinal dysfunction, changes in amount of tissue fluids, dejection, fatigue, and prostration may be absent during the period of duress, only to occur shortly thereafter. Many aspects of the vascular headache attack suggest that it is the sequel to actively operating protective reaction patterns which have been functioning for days, weeks, or longer. These would involve great effort in work, cumulative tension, overalertness, perfectionism, delayed decisions, and the relentless pursuit of approval. With these protective devices the individual is operating at a high cost and has made provisional though extravagant adjustment (15, 44, 89). When such a period is punctuated by an opportunity to operate under less pressure, the organism sometimes seems to pass into a phase comparable to collapse. Headache, perhaps the commonest complaint that confronts physicians, is in nine out of ten instances a manifestation of sustained life stress and of anger and striving. It results, in most instances, from the distension of cranial arteries alone or in combination with sustained contraction of skeletal muscle about the head and neck. (See Figure 59.) Sometimes the latter, as just described, is the prime cause of the pain. Studies of representative cranial arteries in persons with vascular headaches showed that progressive dilatation and distension of involved arteries occurred following the onset of vascular headache. This alteration in the arterial wall was associated with increasing intensity of pain. As the attack subsided, either spontaneously or after the administration of agents and procedures, the distension and the pain diminished concurrently, while the artery returned to its prepainful state. In those with unilateral headache, this sequence of vascular changes occurred only on the painful side. In those with bilateral headache, arteries on both sides of the head

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were involved; when headache moved from one side to the other during a single attack, there was corresponding change in the state of the cranial arteries, first on one side and then on the other. Persons with vascular headache of the migraine type quite commonly had the attitude expressed by "I must do it better and longer than others" and were noted to have exceedingly "labile" cranial arteries as contrasted with those of subjects who never had headaches. The latter exhibited little alteration in the state of the cranial arteries in response to excessive work demands, frustrations, or threatening interviews. In contrast, those who experienced vascular headaches readily responded to discussion of threatening topics with dilatation and distension of cranial arteries. Cranial vasoconstrictive phenomena preceded the actual headache phase of the attack. Characteristic attacks of vascular headache were repeatedly precipitated in such persons (Figures 58, 59, and 60). Pfeiffer and Kunkle also demonstrated the "lability" of cranial vessels in terms of responsiveness to histamine. Smaller amounts of this agent initiated dilatation during periods when the subject was under stress from interpersonal and cultural pressures than during periods of tranquillity. Also the minute vessels of the sclera exhibited increased responsiveness to epinephrin during the period preceding the attack. Edema and hematoma were observed to follow extreme vasodilatation and resulted from diapedesis of blood from minute vessels. Such edema and hemorrhage, when they occur within the cranium, may give rise to parasthesias and disturbances in mentation and motor function. The concept of collapse, however, does not satisfy all the facets of the phenomenology of vascular headache because, as has been demonstrated experimentally (see Figures 57, 58, 59, 60) the attack may be induced in a setting of great stress at the very moment that the organism is roused to a high pitch of anxiety and blocked anger (44). Unless the disturbing incident be looked upon as an overwhelming assault, it is necessary to view such attacks in terms other than collapse. Also, there are bodily changes which seem to represent the purposive or quasi-purposive attempts at some immediate or obvious gain, as exemplified by the man who develops a reversible palsy in one arm when called upon to enter battle. Although such adjustments may conceivably be protective in nature, or sequelae of protective reactions, the evidence available now does not allow of a universal and highly systematized formulation.

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FIG. 64. Increase in facial sebum output during stressful interview inducing anger in an 18-year-old man with acne vulgaris. From H. G. Wolff, T. H. Lorenz, and D. T. Graham, Stress, emotions, and human sebum: their relevance to acne vulgaris, Trans. Ass. Amer. Phys., 1951, 44, 435-44.

The outstanding pattern of emotional response in a series of patients with acne vulgaris was intense anger followed by depression and remorse. A close correlation was found between these phasic emotional reactions, alterations in seborrhea, and exacerbations in the number of acne lesions (Figure 65). Indeed, during periods of stress, skin and mucous membranes may exhibit to a host of foods, pollens, drugs, and simpler chemical agents an increased sensitivity which is not present during periods of relative tranquillity.

LIFE STRESS AND BODILY DISEASE

355 Another example of changing sensitivity of tissue during varying periods of life stress and prevailing emotional states is that supplied by Funkenstein (17). He was able to demonstrate in patients periodically presenting asthma that a given amount of chemical agent which predictably precipitated an asthmatic attack under one set of relatively well-defined circumstances and feeling states had no such effect at another time when the patients were free of asthma but were "mentally ill." A.G. d * AGE ffi ACNE VULGARIS

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FIG. 65. Comparison of the occurrence of phasic changes in mood from anger to remorse with the daily pustule count on the face in an 18-year-old man with acne vulgaris. From Wolff, Lorenz, and Graham, ibid., Trans. Ass. Amer. Phys., 1951, 44, 435-44.

Fragmentation of Protective Reaction: the Principle of Parsimony In adults, noxious symbols seldom evoke a full-blown integrated protective response. Instead, the reaction pattern is likely to be fragmented. That is, the organism reacting to a threatening situation or symbol usually calls into use only a part of an arrangement that might under other circumstances have been more elaborate. For example, defensive reactions involving the airways may include chiefly the nose and a few structures below the nasal airways, excluding the Jung, diaphragm, eyes, and mouth. Or, on the other hand, in the asthmatic, the upper airways may be relatively little involved. Again,

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CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY

the esophagus involved in a pattern of rejection, as manifest in cardiospasm (84), allows nothing to enter the stomach, whereas the gastrointestinal tract below that point may be functioning adequately. The terminal portion of the large bowel may be involved in a rejection pattern, whereas the ileum and the jejunum may be functioning in an average way. Hyperfunction of the stomach and duodenum may be associated with average function in adjacent portions of the gastrointestinal tract. During the hyperdynamic circulatory reaction to stress, heart rate, peripheral vasomotor function, and stroke volume may augment together, or one or more may increase independently of the others. Again, hypodynamic circulatory responses may separately involve heart rate, peripheral vasomotor function, and stroke volume. In the respiratory system, a protective reaction of shutting out, washing away, and neutralizing assaults or threats has been identified (see Figure 66) which involves the airways from the nose to the diaphragm and all the accessory muscles of breathing. The facial muscles, the tear ducts, and even the eyes, become implicated as in weeping. Thus, the nasal airways become occluded and their mucous membranes hyperemic and turgescent, and mucus is vigorously secreted ; the bronchi become contracted, the mucous membranes edematous and wet, blocking the movement of gases, and the diaphragm contracts, limiting ventilation; in combination with the diaphragmatic spasm, the esophagus may be occluded, but far more commonly only a part of the pattern is used. Any of these phenomena may occur alone or in combination with the others, and infrequently are they all involved together. These specific and highly localized responses indicate a parsimony in reaction to symbols. Such parsimony is the keynote to a general picture of an adaptive reaction in which the security engendered is out of proportion to the protection afforded by the response. Thus, despite complaints and troublesome symptoms, the adjustment represented by the protective reaction pattern is on the whole less costly than it might be. Though clumsy, often inappropriate, misdirected, and sometimes containing mixtures of patterns, such protective reactions afford relative tranquillity and in many instances a workable and useful life adjustment, and only become a nuisance or menace when in themselves they threaten the goal of survival. This concept of positive function of patterns inappropriately evoked is not to be confused with that of "secondary gain." The latter applies to incidental advantages which the sick person acquires from family or friends by virtue of being sick.

LIFE STRESS AND BODILY DISEASE

357 In a thesis previously presented, a possible relation of stock factors, "organ selection" and "organ inferiority" was formulated (88). It was suggested that dominant protective reaction patterns are apparently deeply ingrained, since they occur in many individuals of the same stock under analogous conditions. It seems likely that they are stock-bound, analogous to the retriever pattern in dogs, running pattern in the horse, hoarding in squirrels, building and space orientation in birds and insects, and sham death in the opossum. The implication is that the individual and his clan meet life in a particular way and in a different way from the members of other stocks. An individual

2O 3 0 MINUTESINTERYIEW-IWEEPjNG

FIG. 66. Hyperemia, hypersecretion, and swelling of the nasal structures during weeping—the reaction of "shutting out and washing away."

may have been a potential "nose reactor" or "colon reactor" all his life without ever actually having called upon the protective pattern for sustained periods because he did not need to do so. Thus a given protective pattern may during long periods of relative security remain inconspicuous, and then, during stress, become evident as a disorder involving the gut, the heart and vascular system, the nasorespiratory apparatus, the skin, and general metabolism. With the accumulation of data, interest has shifted so as to focus upon the constellation of bodily changes, feelings, and attitudes that a given individual experiences and exhibits in reaction to stress. Thus Graham (24) indicates that the individual with hives is char-

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CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY

acteristically preoccupied more with his resentments than with what to do about them. Grace (23) suggests that the constipated individual exhibits "grim holding on/' reactions and feelings in contrast to those of the same or another person with diarrhea who develops this "riddance" pattern when he feels overwhelmed, has "lost face," has been humiliated, or is faced by circumstances calling for aggressive assertive action which he fears to exhibit. The fact that certain stocks possess proclivities, often long or even indefinitely latent, for the development of specific disorders is strikingly illuminated by the observations of Flynn (13) and Sheldon and Ball (71) made on girl twins aged twenty. These girls, identical as far as can be ascertained by birth history, early photographs, dominant handedness, fingerprints, palm prints, blood groups, somatotypes, hair structure, and skeletal structures by X-ray, nevertheless exhibit important differences. One has had arterial hypertension for about eight years, the other is normotensive. One of the pair—at birth, during infancy, through childhood and adolescence, and even at the time of writing—is "behind" the other. Lighter in weight at birth, somewhat slower in growth, less well developed, burdened with more frequent and severe infections, less outgiving emotionally, less able to learn, less capable of evoking love, less imaginative in work, and less hopeful of success in pursuit of a mate, she has been since infancy in relation to her sister truly in the position of an "also ran." It is this relatively lesser one who has developed the hypertension. Flynn was able to show that both girls vigorously react as regards pressor and other cardiovascular hyperdynamic reactions in response to plunging their extremities into ice water. Also, as regards bloodpressure elevation, both respond vigorously, though not to the same degree, during interviews in which pertinent personal data are brought into focus. It thus appears that not only were they poured out of the same mold as to their structure, but they both respond similarly during stress. They exhibit those protective reaction patterns having to do with mobilization for action. Notwithstanding, only one has felt obliged to strive almost continuously from birth. It may be that the difference between the hypertensive and normotensive is one of congenital defect, but it is hardly likely to be specific in terms of deranged blood-pressure-regulating apparatus. It is simpler to postulate that the hypertensive girl is exhibiting in her cardiovascular apparatus the effects of sustained attempts to compensate for her inadequacies, made especially apparent to her by the achievements of her better endowed sister.

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Cultural Pressures and Protective Reactions It is apparent that individuals present major differences based on stock, temperament, growth, development, and early life experience. Such differences include variations in the capacity to postpone satisfaction, to withstand frustrations, deprivations, and long-lasting stress, to tolerate anxiety and repression, to make new adaptations under changing circumstances, and to tolerate prolonged monotonous effort. Moreover, they vary in their capacity to accept the consequences of an act and, as a corollary, in their capacity to make commitments and assume the responsibility involved in participation in intimate human relations. Further, their capacities to make discriminations and inferences differ greatly. In general, regardless of the sources of his drives and needs, man operates according to recognized principles of conditioning. But, having among his strongest drives his need to be part of a group, the pressures and goals defined by his culture do much to further or block inherent or deep-rooted individual potentialities. Every age has been interested in arranging man as to type, and so to foretell human adversity and behavior, but more recently, and supported by the observations of Sheldon (68, 69, 70), the factors in such typing and predictability have become a little sharpened. Despite what thus appears to be an endless number of variables, there begins to be perceived a patterning within which specific structural arrangements, bodily functions, as well as feelings, emotions, personality, and character features, and behavior preferences form a continuum. When such patterning in an individual is well defined, the reaction to stress is grossly predictable; individuals less well defined as to "type" exhibit less pure and predictable responses. Further, there is a growing awareness that individuals with certain patterns of equipment are especially vulnerable to specific interpersonal and cultural emphases, and that particular bodily illnesses and extreme behavior deviations may then ensue. If we assume, then, that there is a degree of predictability as to reaction for given individual types in specific circumstances and that a conspicuous portion of man's illnesses is a function of his goals, the methods of attaining them, and the conflicts they engender, it becomes pertinent to consider the operation of cultural forces. As data are assembled concerning man's anxieties, and how they are initiated and resolved, four generalizations are coming to be recognized (66, 73). r irstly, the "dangers" for man are in large part defined in the mores,

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folklore, and taboos of his specific culture. Secondly, the "dangers" so defined are overstated or exaggerated, so that the individual has to deal with the anxiety imposed by his culture, plus the actual danger. Thirdly, along with such culturally engendered anxiety, there are developed and prescribed methods for dealing with it. These methods of resolution become formalized and effective in old and stable cultures. Fourthly, in cultures changing or deteriorating, the methods of resolution of anxiety and tension cease to be operative long before the tension-producing factors lose their potency. Or, in other words, when a culture deteriorates the anxiety-resolving systems break down before the culturally engendered anxieties become attenuated. For example, among the Hopi Indians, in recognition of the ominous nature of snakes, it is decreed that one may not tread on the track of a snake. The one who offends will experience sore ankles or legs. Should one by accident or necessity tread in the snake's track, the Hopi culture deals with the crisis through the medicine man, who has a traditional procedure for neutralizing the untoward effects of the breach. Among the younger Hopi, however, who have been more exposed to the alien influences of United States schools, missionaries, etc., belief in the medicine man and his power is weak or absent. Yet the taboo concerning snake tracks persists, so that the man who is unfortunate enough to step on one often experiences pain in the ankles and legs, for which he has at his command no satisfactory therapeutic procedure (72). Thus it would appear that societies undergoing rapid cultural change are especially likely to create settings which engender insecurity and hence the development of protective reaction patterns. It is alleged, though unsupported by statistical study, that in central India diarrhea, ulcerative colitis, neurocirculatory asthenia, and asthma are far more common among the relatively opulent, wellnourished, hygienically oriented, educated, so-called Westernized Indians of the large communities as compared with the group of ignorant, unschooled, unhygienic, highly religious, and often overworked and underfed non-Westernized people of small villages. The former are adjusting themselves to a new set of values and are caught between two systems, finding little support in either. Among these are outwardly bland but inwardly striving, dissatisfied, tense, anxious, and hostile persons who exhibit offensive and defensive protective patterns. It is of interest that the protective symptoms mentioned, when they occur in our culture, are commonly found as described above in essentially passive, nonparticipating persons who have been

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made angry by stresses that they cannot or do not encompass. The older and more stable cultures are more likely to provide methods for dealing with accumulating tensions and dissatisfactions. Also, the likelihood of development of such frustrations and conflicts is less great in societies where social hierarchies and one's "place in life" are defined and generally known and accepted, and the pressures to move from one social status to another are minimal. The acceptance of what life "hands out" is easier if all those about one are apparently sharing the adverse as well as the satisfying experiences. If, however, it is felt that some groups or individuals are immune or unduly protected from the blows of fortune, or if there be a cultural or educational force which suggests that one's lot might be improved, that one is exploited, that one's load might be lightened, that those things one has accepted as inevitable and imminent might be avoided if certain steps be taken, then there develops conflict, with feelings of frustration, anger, humiliation, and anxiety. It is of interest that identical protective reaction patterns and their related disease syndromes exhibit themselves in cultural settings in which almost opposite social pressures are being exerted, i.e., the pressure on the young American male toward emancipation from the parents' position of authority and "standing on his own feet" in contrast to the Japanese cultural pressure which shapes a young man to assume a lifelong burden of obligation and debt to his parents, with filial piety and acceptance of their dominance ( 5 ) . This generalization would seem to support the view that it is not the particular nature of the forces or pressures or preferences that constitute stress for the individual in any particular society but the amount of conflict which is either directly or indirectly engendered in him by his cultural medium. For example, it is not the specific attitude toward parents or power or possessions or toward sexuality or actual sexual practices or the hours of work or even the type of work or the amount of individual freedom of action, but the conflict of which all these may be the factors that is pertinent to the development of protective reaction patterns and disease. Thus, an amassing body of data demonstrate further the growing importance to medicine of the recognition that for man reactions to threats or to symbols of danger, especially when sustained, may be more important than response to assaults. Certainly many aspects of disease, including those associated with tissue damage and ending in death, may be looked upon as functions of man's goals, his methods of achieving them, and the conflicts they engender.

362

CONTRIBUTIONS TOWARD MEDICAL PSYCHOLOGY REFERENCES

1. ACKERMAN, N. W. Character structure in hypertensive persons. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 900. 2. ALMY, T. P., KERN, F., JR., and ABBOT, F. K. Constipation and diarrhea as

reactions to life stress. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 724. 3. BAKKE, J. L., and WOLFF, H. G. Life situations and serum antibody titers. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 307. Also Psychosom. Med., 1948, 10, 327. 4. BARKER, W., and BARKER, S. Experimental production of human convulsive brain potentials by stress-induced effects upon neural integrative function: dynamics of the convulsive reaction to stress. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 90. 5. BENEDICT, R. The chrysanthemum and the sword. Boston: Houghton Mifflin Co., 1934. 5a. BERRY, CHARLES. Personal communication, 1949. 6. BISHOP, LOUIS FAUGERES, JR., and KIMBRO, R. W. Neurocirculatory asthenia.

/. Amer. med. Ass., 1943, 122, 88. 7. CANNON, W. B. Bodily changes in pain, hunger, fear, and rage (2d ed.). New York: Appleton-Century-Crofts, Inc., 1929. 8. CHAPMAN, W., LIVINGSTON, R. B., LIVINGSTON, K. E., and SWEET, W. B.

Possible cortical areas involved in arterial hypertension. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 775. 9. COHEN, M. E. Life situations, emotions, and neurocirculatory asthenia (anxiety neurosis, neurasthenia, effort syndrome). In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 832. 10. DAVEY, L. M., KAADA, B. R., and FULTON, J. F. Effects on gastric secretion

of frontal lobe stimulation. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 617. 11. DIETHELM, O., FLEETWOOD, M. F., and MILHORAT, A. T. The predictable

association of certain emotions and biochemical changes in the blood. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 262. 12. EWELL, J. W., MUNSON, P. L., and SALTER, W. T. Endocrinopathy during

education for professional careers: effects of therapy. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 458. 13. FLYNN, J. T., KENNEDY, A. K., and WOLF, S. Essential hypertension in one

of identical twins: an experimental study of cardiovascular reactions in the Y twins. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 944. 14. FRIED, R. I. Socio-emotional factors accounting for growth failure in children as measured by the Wetzel Grid. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 317. 15. FRIEDMAN, A. P., and BRENNER, C. Psychological mechanisms in chronic headache. In Association for Research in Nervous and Mental Disease, Life stress

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and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 605. 16. FRIEDMAN, M. Hyperthermia as a manifestation of stress. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 433. 17. FUNKENSTEIN, D. H. Variations in response to standard amounts of chemical agents during alterations in feeling states in relation to occurrence of asthma. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 566. 18. FURER, M., and HARDY, J. D. The reaction to pain as determined by the galvanic skin response. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 72. 19. GANTT, W. H. Disturbances in sexual functions during periods of stress. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 1030. 20. GOODELL, H., GRAHAM, D. T., and WOLFF, H. G. Changes in body heat regula-

tion associated with varying life situations and emotional states. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 418. 21. GOTTSCHALK, L. A., SEROTA, H. M., and SHAPIRO, L. B. Psychological conflict

and neuromuscular tension: I. Preliminary report on a method, as applied to rheumatoid arthritis. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 735. 22. GRACE, W. J. Life situations, emotions, and chronic ulcerative colitis. In Association for Research in Nervous and Mental Disease, Life stress and bodily disease. Baltimore: The Williams & Wilkins Co., 1950. P. 679. 23. GRACE, W. J., WOLF, S., and WOLFF, H. G. The human colon: experimental

24.

25. 2627.

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