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Hoch Polatin 1949
Hoch Polatin 1949
For some time, the writers have been following a group of pa-
tients who, in their opinion, show a rather definite clinical symp-
tomatology which, however, is little known or not sufficiently ap-
preciated. These cases are very often diagnosed and treated as
psychoneuroses. Offer this error is made, not only after seeing
the patient a few times, but often over a long period. Many of
these patients have been analyzed for a considerable period of
time; and the suspicion 'has never been raised that they were not
psychoneurotic. Some psychiatrists concede that the clinical and
psychodynamic structure of these cases differs from the neuroses
--although re~aining a great deal of resemblance to the neurotic
disturbances--and call them "borderline cases." Again, others
are struck by the similarity of the mental changes and personality
structure to schizophrenia and will diagnose them as schizo-
phrenics. The writers would like to emphasize that this group of
patients is not smM1. They are, therefore, not advocating here a
more refined .classification and do not wish to indulge in diagnostic
gymnastics, but do wish to emphasize that many patients in this
category are admitted to mentM hospitals, and that probably a
much larger number are treated in the offices of private psy-
chiatrists.
The actions of these patients, the prognoses of their cases and
the therapy, as we shall see, differ markedly from those of the
ordinary psychoneuroses. The writers feel justified in classifying
these patients with the schizophrenic reactions because many of
the basic mechanisms in these cases are very similar to those com-
monly known in schizophrenia. Particularly, if the disorder should
show a progressive course, symptoms will often occur which will
make the diagnosis of schizophrenia convincing even to the most
skeptical. It is interesting that very little can be found in the psy-
chiatric literature about the differential diagnosis between psy-
choneurosis and schizophrenia. Even Bleuler, who devoted a life-
time to studying this latter disease, only mentions the differentia-
tion in a perfunctory way, calling attention to the fact that in
neurasthenia, in hysteria, and in obsessive-compulsive neurosis es-
• the departments of research and clinical psychiatry, /qew York State Psychi-
atric Institute.
PAUL I-IOCtt~ M. D.~ AND P H I L L I P POLATII% 1Vf. D. 249
pecially, it is necessary to be alert to the problem of a schizo-
phrenic development.
The concept of schizophrenia has undergone several evolutions.
Originally dementia prmcox was diagnosed only when deteriora-
tion was present, and some psychiatrists in connection with the
cases to be presented here will call attention to the fact that they
do not show typical schizophrenic regression and deterioration.
This is true for a number of patients. In others, however, even
this criterion of schizophrenia can be supplied because a fair num-
ber of the cases cited-- followed up for years--showed deteriora-
tion, and certification was necessary.
Bleuler pointed out the fact that ,the clinical classification can-
not be based solely on the final outcome of the disease and that
clinical, and especially psychological, criteria of schizophrenia
exist, on which the diagnosis can be based. He stressed especially
his point of view that in schizophrenia there are basic symptoms
and accessory symptoms. Disorder of associations, rigidity of
affect, ambivalence and dereistic thinking were considered pri-
mary, whereas hallucinations and delusions, catatonic symptoms,
etc., were considered secondary, and their presence for the diag-
nosis not a necessity. This concept was generally accepted and
even applied, for instance in cases of simple schizophrenia. Never-
theless most psychiatrists felt comfortable with the diagnosis of
schizophrenia only if delusions, hallucinations or gross regressive
manifestations were present. It is furthermore important to em-
phasize that from the quantitative point of view even these symp-
toms had to be rather prominent before the diagnosis of schizo-
phrenia was and is made. The final and more subtle emotional,
intellectual and psychodynamic changes were rarely appraised
properly--especially not in the types of cases here presented.
In establishing the diagnosis of the pseudoneurotic form of
schizophrenia, it will be necessary to demonstrate the presence of
the basic mechanisms of schizophrenia. These basic mechanisms
differ qualitatively and quantitatively from mechanisms seen in
the true psychoneuroses. None of the symptoms, which will be
enumerated, is absolutely characteristic of schizophrenia. Such
a symptom is significant only if manifest in a certain degree and
only if several of the mentioned diagnostic criteria occur simul-
taneously. The diagnosis, therefore, rests on the constellative
evaluation of a group of symptoms even though in any given case
250 PSEUDONEUI~OTIC
FOR1V~SOF SCI~IIZOPIIREI~IA
it is not necessary to have all the symptoms present which are now
to be discussed, The basic schizophrenic mechanism, the autistic
and dereistic life approach are present in a subtle way in all the
cases presented; but, admittedly, it remains very much a subjec-
tive issue with each diagnostician to appraise this symptom. There
is no objective way to demonstrate it clinically. The withdrawal
from reality usually, however, is much more general than is seen
in the neuroses, even in those with some schizoid features. Ambi-
valence, another basic mechanism in schizophrenia, is usually pres-
ent if carefully evaluated. In contrast to the neuroses, a quanti-
tative difference is immediately obvious. The ambivalence is not
localized, but it is diffuse and widespread involving the patient's
aims, his social adaptation and his sexual adjustment. From a
quantitative point of view the ambivalence in these cases of schizo-
phrenia is not so much an ambivalence as a polyvalenee. Not
only two contradictory impulses are present, but many constantly
shifting notions in the approach to reality.
The affective behavior in these patients is often similar to that
seen in the full-fledged cases of schizophrenia even though much
less conspicuous and therefore often missed. This behavior is
more readily observed in patients who are hospitalized than in
those who are seen in office visits. Such patients very rarely show
an impoverished, rigid, or inflexible affect. Some inappropriate
emotional connections, however, are not rarely present, and a lack
of modulation, of flexibility in emotional display is often demon-
strafed, especially under sodium amytal. Many of these patients
show the cold, controlled, and at the same time, hypersensitive re-
actions to emotional situations, usually over-emphasizing trivial
frustrations and not responding to, or by-passing, major ones. At
times lack of inhibition in displaying certain emotions is especially
striking in otherwise markedly inhibited persons. For example,
a shy, timid person suddenly goes into a rage directed against an-
other person, without being able to motivate this great emotional
display sufficiently. T]~e expression of overt hatred particularly
toward members of their own families is rather characteristic for
these patients. The hate reaction is much more open and much
less discriminating than seen in the neuroses.
From the diagnostic point of view the most important present-
ing symptom is what the writers call pan-anxiety and pan-neuro-
sis. Many of these patients show, in contrast to the usual neurotic,
PAUL HOCII~ iVf. D.~ AND PHILLIP POLATII% IV[. D. 251
Since they were already nervous, this additional worry and guilt-
feeling might make them become " i n s a n e , " which would make the
patient in turn feel so guilty and ashamed that she would probably
have to commit suicide. She also had fears that she might have
delusions or hallucinations. She said the following: " I ' m afraid
I will have hallucinations. I know I may never have them, but I ' m
afraid if I keep on thinking about them, I will develop them. I ' m
afraid of getting a psychosis; of getting so I wouldn't be aware
how much I ' m suffering."
S. S. also began to develop compulsions, such as having to turn
out the light about six times before going to bed, having to read
things over, having to leave her shoes on a parallel line when she
went to bed, Generally, she was careless, however, about her dress
and personal hygiene, and was listless and indifferent. Coming to
New York, the patient read a book on psychiatry. After reading
it, she said, " I was a schizophrenic. The book said it's incurable.
Lately I thought I ' m not a schizophrenic because I have too much
awareness of my surroundings." Three years ago, when she was
visiting her relatives, they found her moody. She sometimes
stayed in bed all day Sunday, not even dressing or going out of
the house. She was afraid then, and she was very conscious of it.
She believed no boy could love her because of her looks. She was
rigid and particular about her eating; had to eat at exactly set
times. She spoke about getting fresh food and a balanced diet,
but she ate very little. She went to work regularly. About one
and one-half years ago, she went hol~e from work shaking all over
and unable to talk to any one. The girl would not reveal anything
about her sickness, saying, "You won't understand." She ap-
peared to be disturbed that day and had a dazed appearance; had
a fixed look in her eyes. She was taken to an endocrinologist, who
found her resistive to examination, diagnosed schizophrenia, and
advised psychiatric treatment.
The patient was treated in a clinic from September 1945 to 1946.
The psychiatrist who treated her stated: " T h e diagnosis was not
quite clear in the beginning. She had many symptoms of obses-
sive neurosis, but longer observation made it clear that she was a
simple schizophrenia with obsessive ideas, with flattened affect,
but a very well preserved personality."
Hospital Admission Note. The patient was admitted to the
Psychiatric Institute on January 27, 1947. On admission, she
260 PSEUDO~EURO~IC
FOI~S OF SCHIZOF~ENIA
stated: " I have fears of food; I have fears of something happen-
ing to my family; I cannot sleep; I get depressed; I become tense,
anxious, and agitated." She was co-operative and pleasant dur-
ing the interview and her conversation was relevant and coherent.
Her affect showed tension with considerable anxiety and moderate
depression. She denied hallucinations or delusions, and she was
well oriented in all spheres.
A t~titude and General Behavior. Asthenic, frail looking, but rea-
sonably active, S. S. looks younger than her 21 years. There is
average neatness of dress, without peculiarities of clothes or
make-up; she is reasonably clean. There is little enthusiasm for
eating, her mood is generally apathetic and moderately depressed;
but, at times, she is alert and even mildly excited. There is little
spontaneous entry into recreational activities. S. S. indicates an
interest in making friends but her choice of conversational topics
is usually her own illness and details of the illness of another pa-
tient about which she is curious. She has not established any co-
hesive friendships on the ward. From the moment of hospital ad-
mission, she talked spontaneously and rather copiously about her
illness and her own theories of its cause.
Ait~titude and Behavior During I~terview. When being inter-
viewed, S. S. is reasonably attentive and co-operative, and is fairly
relaxed and natural in manner. Her facial expression is moder-
ately expressive, and is appropriate to her mood. Initially, she
looked mildly depressed but smiled at times when lighter topics
were introduced into the discussion. She appears rather listless and
shows little motor activity during interviews. No tremors, tics,
etc. She looks rather hypotonic, and her posture is rather lax and
"slouchy." Retardation is not apparent.
~tream of Mental Activity. S . S . is rather self-absorbed, but at
times is spontaneously productive, generally about her own prob-
lems. Her speech is relevant, coherent and free from gross lan-
guage-deviations. Productivity is normal. She is not distractible
by external stimuli but tends to wander gradually from a given
topic to related matters which she feels have a bearing on the sit-
uation. Reaction time is within normal limits, but varies with
topics and her related affect.
Emotional Reactions. Generally, S. S. appears mildly depressed
and apathetic but is not retarded and is reasonably labile in her
mood. Mood (as expressed in appearance and speech) is usually
P A U L H O C H , NI. D.~ A N D PHILLIP POLATII% M . D . 26]
ing to get ahead." She believes that all her dreams have a signifi-
eanee but not similar to this. She is markedly eatathymie. She
believes that she may attain anything by wishing. Her thoughts
are, in fact, constantly wish desires, wish fulfillments. She be-
lieves that by wishing she can control, she believes in thought
magic, she ean kill by ideas.
P. C. related in another interview that she feels torn between
two conflicting emotions concerning her husband and children. She
wants to be a good wife and mother. At the same time, she resents
very much that she is " t i e d down"; that she is not free to live her
own life. She would like to become a writer. Sexually, the hus-
band is repulsive to her, and she is frigid with him. With the first
husband, she had sexual satisfaction, mainly obtained by oral
activity.
The Rorschach examination revealed several "contaminated"
responses which were considered pathognonlonic of schizophrenia.
Summary of Satient Fea~tures. The central theme here is ag-
gressive reaction formation around which a great deal of guilt
feeling is generated. Aggression is partly outward (killing the
husband and children, or the frustrating environment), partly in-
ward (suicidal ideas, ideas of unworthiness).
Some projection is present, which is unusual; she fears being
killed by her husband. The patient's mental disturbance showed
three levels--neurotic, depressive and schizophrenic. On the neu-
rotie level, P. C. displays symptoms of anxiety hysteria, phobic
and obsessive manifestations. On the depressive level, there is a
marked introjeetion; deep hostility toward the mother; marked
ambivalence toward the father; a rigid conscience with a tendency
to rebel ; strong oral drives ; the seeking of expiation of guilt. This
is not on an unconscious but practically on a conscious or precon-
scious level. On the schizophrenic level, this woman is introverted,
loosely connected with the environment, replacing reality with
day-dreaming, always anxious, catathymie. In her paintings, the
patient shows symbolic condensations and fragmentations. She
believes in thought magic, projects h e r ideas into utterances and
performances. She animates things. Boundaries between the ego
and the world are hazy. A tendency to cosmic fusion is present.
Sexually, P. C. shows a strong narcissistic, exhibitionistic trend,
276 PSEUDONEUROTIC FORMS OF SCHIZOPHRENIA
BIBLIOGRAPHY
Bleuler, E. : Textbook of Psychiatry. English trans, by A. A. Brill. Macmillan Com-
pany. New York. 1924.
Fenlche], Otto: PsFchoanalytlc Theory of Neurosis. W . W . Norton & Company. New
York. 1941.
Polatin~ Phillip~ and I-Ioch~ Paul: Diagnostic evaluation of early schizophrenia~
ft. N. M. D , 105:3, March 1947.