Showing the technique of injecting dye into spinal cord of a child, together with a discharge of dye through an opening at lower part of conus (indicated by black spot).

THE CONTENT OF THE SCHIZOPHRENIC
CHARACTERISTICS OCCURRING IN
AFFECTIVE DISORDERS.*

BY PHYLLIS GREENACRE, M. D.,

Henry Phipps Psychiatric Clinic, The Johns Hopkins Hospital,
Baltimore, Md.

The more pronounced schizophrenic processes present usually the appearance of discrepancies in thought and reaction, defects in interest and emptiness or silliness of affective response; but frequently the content of the various stages in this development, the substance expressed in the oddities of behavior, is obscured by the absence of affect, and by the seclusiveness and inaccessibility. The observer must then be content mainly with a surface description of the mannerisms, grimacing, peculiarities of speech and explosiveness of tantrum, which leave him with as unsatisfied a feeling as though he were looking at a mutilated picture in which he pieces together the fragments with the help of his imagination, or permits them to lie unassembled, open to hardly more than a description of their shape and texture. It is a matter of common experience that numerous schizophrenic symptoms occur either singly or in constellations in affective psychoses, where the affective response is primarily congruous but is associated with some degree of projection and distortion. This group of "atypical" affective disorders appears particularly favorable for the study of the content and origins of the schizophrenic features included in it: the patients are frequently accessible, the disorganization is neither so complete nor so bewildering as in many cases of the outspoken dementia præcox. The present paper deals essentially with the schizophrenic content, leaving the prognostic evaluation and the dynamic interpretation of the symptoms for further analysis and communication. In this series of 40 cases, these symptoms fall according to their form into five classes: (1) Distortions and misinterpretations of actual occurrences (de

* Read at the seventy-fourth annual meeting of the American MedicoPsychological Association, Chicago, June 4-7, 1918.

lusions of reference and persecution); (2) influence and passivity feelings as expressed in automatism, mind reading, electrical influence and similar phenomena; (3) hallucinations; (4) gross distortions of body sense and body appreciation; (5) incongruous behavior, occurring either episodically as "antics," or more persistently but not in keeping with or apparently motivated by the prevailing affect.

Of the schizophrenic characteristics seen in these "atypical" affective disorders, the distortion of actual events is apparently the first and readiest step in the process of projection. Ideas of reference occur in over half the cases studied. These are usually met as beliefs of the patient that the behavior of others is fraught with meanings especially applicable to himself: that others are discussing his discomforts, making remarks or doing things to deride him. The delusions appear related especially to a sensitiveness which makes the patient irritable to the criticisms of others, which he cannot assimilate as rational standards such as would serve as guides or be of corrective value to him; but rather as criticisms which make him hide his difficulties lest they excite unfavorable comment. This fear of criticism, mingled with the actual conviction of its existence, is but a step from the line which every individual crosses occasionally and is generally designated as "self-consciousness or simply as "touchiness." But when the fear becomes so dominating that the individual no longer suspects only those who might have knowledge concerning him, but feels that he is the object of talk among strangers or casual acquaintances, mere touchiness has indeed reached a degree obviously pathological. Ideas of reference occur in affective states in proportion to the degree of defense which the person feels he must place between others and the situation which he himself finds unacceptable: they are determined not only by the constitutional sensitivity furnished by the individual but often are plainly the real upshot of crucial situations which involve some fear of detection. For example, the man who has lost his position may unreasonably feel that others suspect his failure and are looking at him with contempt or pity; and the elated lover may feel that others share his exuberance or read his triumph. Many of the delusions of reference in affective disorders occur also as substantiations of the affect-especially in the depressions, where

there is a bolstering up of the self-condemnation by the conviction that others are similarly condemnatory. It becomes necessary then in considering the significance of the interpretations of reference to determine their relation to the onset of depression: whether they are mainly secondary; of the character of substantiation, or whether they are an early symptom-the first step in projection and then usually associated with peevishness rather than sadness. A further step consists in feelings of persecution which, in the affective psychoses, are usually elaborations of the reference ideas, with which they are commonly associated, and with which they present fundamentally the same problem. Their onset appears frequently to be determined by definite situations of disappointment: the patient finds himself inadequate in that his ambitions and expectations are unrealized, yet he is unable to accept his insufficiency without placing blame, which concentrated on himself (without analysis) feeds his self-accusations of unworthiness, or, when attributed to his associates, becomes the nucleus of a feeling of injustice, slights, or aggressive persecution. Illustrative of this mechanism is the following case:

F. S. B., a pharmacist of 41, who came to the clinic in 1915 with the complaint of depression. He had been a seclusive, rather dull child, who graduated from the eighth grade at 18 and then took a correspondence course and became a pharmacist, and for the past 10 years worked in an institution. He was over-scrupulous, tried to be perfect in his work, although he was actually mediocre, and he worried. At 40, after losing his savings in a bad investment, he became depressed and upset, for this meant that he could not marry as he had planned. After about six months of depression, he began to be suspicious, felt that the bank officials had purposely ruined him; that others envied him his job and were trying to lead him into drink so that he would lose his position. He then became afraid that a woman with whom he had illicit relations would inform his fiancée. He went to his mother's home where for two weeks he lay without speaking. On admission to the clinic, a few days after this, he was moderately depressed, kept apologizing for trivial things which he seemed to feel he might have done wrongly, he acted as though he expected to be ordered around like a child. For 10 days he remained for the most part in bed-mute, rigid and cataleptic; then he gradually improved and in two months had returned to his former level. Here we have a man who early showed a tendency to sensitiveness, set standards much beyond his mediocre assets and consequently burdened himself with a large number of disappointments. At 40, his marriage is blocked by his loss of money. But the disappointment is not accepted by the patient; it was at first met rather naturally with depression, but then by evasion and projection of the disappointment responsibility.