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3’HYSIOLOGICAL RESPONSIVENESS
IN REACTIVE AND PROCESS
SCI:£.IZOE’HRENIA

THESIS FOR THE DEGREE OF PH. D.
MICHIGAN STATE UNIVERSETY

SPENCER DEVAULT
1955

THESIS

This is to certify that the

thesis entitled

Physiological Responsiveness in Reactive and
Process Schizophrenia

presented by

Spencer Devafilt

has been accepted towards fulfillment
of the requirements for

Mdegree in PS‘ ChOlOfo?’

4%. W

Major professor

November h, 1955
Date

 

0-169

PHYSIOLOGICAL RESPONSIVENESS IN REACTIVE

AND PROCESS SCHIZOPHR ENIA

B y ‘
l

SPENCER, DEVAULT

A THESIS

Submitted to the School of Advanced Graduate Studies of
Michigan State University of Agriculture and Applied
Science in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

D epartm ent of Psychology

1955

ABSTRACT

It has been suggested that the mental diseases commonly
diagnosed as schizophrenia (of four classical types) may be dis-
tinguished on the lines of two basically different groups. These
types, referred to as reactive and process schizophrenia, were
differentiated in this study on the basis of case history and clin-
ical data, according to the following criteria: (1) prepsychotic per—
sonality; (Z) precipitating stress; (3) onset; and (4) clinical picture.
The comparison of these two groups on the basis of physiological
reactivity to various stimuli was the primary purpose of the study.

Two groups of chronic schizophrenics, eighteen in each
group, and a group of eighteen normal control subjects were stud-
ied. Four pictures, one of neutral value and the others represent-
ing common conflict areas (hostility, dependency, sex) were used as
stimuli. A loud bell preceded by a verbal warning was also used.
The reSponses measured included base levels and amplitude of
heart rate and GSR changes and arousal and recovery time of GSR.

The reactive group of schizophrenics showed a significantly

higher base level heart rate than either the normals or the process

ii

group. There were no significant differences between the groups in
base GSR.

The reactives responded like the normals in amplitude of GSR
and heart rate change, except after the warning where their response
was lower. They tended to make a slower recovery than the process
or normal groups.

Amplitude of GSR for the process group was lower than for
the other groups. The mean heart rate changes of this group were
all negative and significantly different from the changes of the nor-
mals and reactives.

These results were interpreted to mean, primarily, that at
least two groups, differing in physiological response to certain stim-
uli, can be distinguished within the classification of schizophrenia.
These groups do not seem to be independent of the traditional sub-
types, but can be differentiated independently of them. Both groups
manifest withdrawal at a social level and in overt activity. They
differ, however, in the extent of the withdrawal. The reactives were
affected by other stimuli and responded strongly to them, their re-
sponse reaching or exceeding the normal level. The withdrawal of
the process group seemed to go much further, their responsiveness
in this study being confined to what seems to be a reflex reSponse
to sensory stimuli.

iii

The results thus indicate a more significant basis for clas-
sifying schizophrenia than the traditional four subtypes. The reactive-
process distinction provides a differentiation meaningful in terms of
etiology, treatment, and prognosis, and can discriminate these groups

at both physiological and psychological levels.

iv

ACKNOWLEDGMENTS

The writer wishes to express his appreciation to the many
persons whose assistance was of such help in this research. Dr.

G. M. Gilbert, besides giving constant encouragement and advice,
provided some of the basic ideas for the study. Dr. D. M. Johnson
and Dr. M. Ray Denny similarly aided with their many suggestions
and criticisms.

The Clinical Psychology Staff and many of the other personnel
of the Fort Custer Veterans Administration HosPital were most help-
ful and cooperative with their time and services, and a special note
of thanks is due to Dr. Paul Greenberg for his guidance at every
stage of the project. Dr. L. M. Baker also was of much assistance
with the technical aspects of the study, particularly in the use of
the polygraph.

Finally, credit is due to Gea Nall, who patiently and accu-
rately did the difficult task of tabulating the data, as well as the

major portion of the typing and preparation of the manuscript.

TABLE OF CONTENT S

INTRODU CTION ...............................

SCHIZOPHRENIA AS A HETEROGENEOUS GROUP:
THE REACTIVE-PROCESS DISTINCTION .......

THE PROBLEM OF EMOTIONAL RESPONSIVENESS
The Low Reactivity View ................
The Normal or Excess Reactivity View ......
Summary of Studies of Responsiveness .......
Shortcomings of These Studies .............

Stage of schiz0phrenia ................
Experimental stimuli .................
Measures of response .................

STATEMENT OF THE PROBLEM ............
Criteria for Reactive and Process Schizophrenia
Stimuli .............................
Responses ...........................
Hypotheses ..........................

METHODOLOGY .........................
Subjects ............................
Measures ...........................

vi

 

12

13

15

17

l7

l9

19

21

23

23

26

28

29

32

32

35

Page

Procedure ................................. 36
RESULTS ................................... 40
DISCUSSION .................................. 46

Interpretation of the Response Pattern:

Reactive Group ............................. 47

Interpretation of the Response Pattern:

Process Group .............................. 50

General Considerations Concerning

Responsiveness ............................. 51
IMPLICATIONS FOR FURTHER RESEARCH ........... 54
SUMMARY ................................... 57
BIBLIOGRAPHY ............................... V 62
APPENDIX I ................................. 68
APPENDIX 11 ................................. 71

vii

TABLE

I.

II.

III.

IV.

LIST OF TABLES

Age and Length of Hospitalization .............
Patients' Subdiagnoses .....................

Heart Rate Base Levels, Differences
Between Groups, and t-Ratios ................

Means of Each Group for All Measures
of Reactivity and Stimuli ....................

Differences and Significant t-Ratios
Between Group Means on Measures
of Reactivity ............................

41

42

43

INTRODUCTION

The concept of schizophrenia as a disease entity is one of the
most confused and controversial in modern psychopathology. There
has been a growing awareness of its complexity as a diagnostic
group and a great variety of disturbed behavior has often been in—
cluded in the category. Much of this behavior is not consistent with
the traditional view of the disorder as originally developed by Krae-
pelin (3, 10, 28), and later modified by Bleuler (5).

Kraepelin, confronted with a wide array of poorly classified
states of insanity, sought to isolate more definite disease syndromes.
One common pattern he described was a disease of early onset,
characterized by a progressive withdrawal from reality, hallucina-
tions, delusions, negativism, bizarre thinking and behavior, and blunted
or inappr0priate affect. These conditions were said to occur in the
absence of primary disturbances of perception and memory, with a
relatively clear "sensorium." Included in the syndrome were three
symptom groups which had earlier been considered as separate en-
tities: the catatonic, hebephrenic, and paranoid groups. Common
among them, according to Kraepelin, was a disease course originating

early in life and leading to a demented end—state. This course was

emphasized by Kraepelin in his name for the disease, dementia
praecox, and served to differentiate the group from others that did
not show the tendency toward early dementia, especially the manic-
depressive psychosis.

Bleuler, several years later, revised this conception, renaming
it schizophrenia, and expanding the syndrome by including another
group, the simple type. He described the schizophrenic group as
characterized by a dissociation of the functions of the personality
and a primary disorder of thinking, and emphasized that emotion is
not always absent. In his discussion of the affect of the schizo-
phrenic he states that in the beginning of the disease the oversensi-
tive patient consciously and deliberately isolates himself to avoid
emotional arousal, but nevertheless retains the capacity for emotional
experience. Later on in the course of the illness there is still emo-
tion present but in an ”abnormal basic state," "a different adjust-
ment of the affective zero point" (5, p. 43), with outward indifference
and apathy. He also speculated as to the possibility of a later re—
duction of the group into several entities, according to etiology, and
did not entirely accept Kraepelin's belief in the organic basis of the
disease. He further disagreed with Kraepelin in not accepting the
latter's view of a necessarily bad prognosis, in a progression to-

wards dementia.

Many contradictions to these classical descriptions are found
today, both clinically and in the results of experimental studies. We
find in practice that almost any patient who presents a picture of
blunted affect or hostile attitudes is apt to be labeled schizophrenic,
and the use of the diagnosis varies tremendously from one hosPital
to another, depending on the orientation of the particular diagnosti-
cian.

Viewpoints in regard to etiology share in this controversy,
and they range from such causes as a constitutional defect or an
organic brain disease to psycholOgical trauma. Symptomatology
varies similarly: there is often confusion, distortion of perception
and memory, and acute outbursts of anxiety and emotion in patients
diagnosed schizophrenic. The onset may be early and insidious, as
Kraepelin stated, or sudden, acute, and relatively late in life, and a
particular case does not necessarily end in dementia; social recov-
eries do occur (10, 29).

The concept of the four clinical types as all distinct varieties
of the same disease has also been criticized (7). Much depends, in
this instance, on what is emphasized in order to construct a usable
classification and frequently patients are found who have symptoms

cutting across several of the traditional subgroups.

This disagreement has led to the lack of any consistent ra-
tionale for treatment or any definite standpoint in regard to prOg-
nosis, and points to the need for a sounder basis for diagnosing
schizophrenia, both as a group and in differentiating subgroups. The
situation has been recognized to some extent in the modern term
"schizophrenic reaction" (63). This name seems to imply a group
having broad similarities in symptoms but possibly being quite
heterOgeneous in other respects; unfortunately not much more is

made specific in the official psychiatric classification.

SCHIZOPHRENIA. AS A HETEROGENEOUS GROUP:
THE REACTIVE-PROCESS DISTINCTION

While this issue of the heterogeneous nature of schizophrenia
has not been explicitly recognized in the official nomenclature, there
has been a growing tendency to take account of the problem in the
study of the disease. As mentioned above, Bleuler did not consider
schiz0phrenia as necessarily homogeneous and believed that there
might be a later reduction of it into several entities, each with a
particular etiology and outcome. Since his time several workers, on
the basis of clinically formed Opinions, have attempted to deal with
the question. These people, although using different terms among
themselves and forming a minority in psychiatric thinking, have been
fairly consistent in pointing to two large divisions within the category
of schiZOphrenia, differentiating them in terms of onset, symptoma-
tology, outcome, and sometimes etiology. Thus Sullivan held that
there were two unrelated but often confused syndromes: dementia
praecox, an "organic, degenerative disease" with an insidious onset
and poor prOgnosis, and schizophrenia, "primarily a disorder of
living" with an acute onset due to situational stress and a good
prOgnosis (58). Hoskins recognized the situation in his comparison
of schizoPhrenia to such entities as "headache" and "hypertension,"

5

”. . . each of which has a common core manifestation but each of
which may represent very dissimilar disorders" (28, p. 72). Strecker
and Willey gave an outline for differentiating the two groups on the
basis of prOgnosis. They consider good affect as the best index of

a good prOgnosis. A ”basic and constitutional seclusive makeup" is
a poor sign but an acute, stormy onset with a significant precipitat-
ing situation indicates a better prOgnosis (56).

Langfeldt, in an extensive study of the outcome of schizo-
phrenia, went even further in his view that percentage reports of
recovery merely indicated the relative proportion of true of "proc-
ess" versus acute 0r "schizophreniform" cases treated. He was
the first to use the term "process schizophrenia" for the poor prog-
nostic group (39).

D. E. Cameron has studied the disorder in terms of the type
of onset. His findings, supporting the two-entity view, Show that
there are two main groups of early symptoms, one being character-
ized by hypoactive behavior and the other by hyperactivity. His evi-
dence indicates that the hypoactive symptoms are usually present
for a longer time before hospitalization than the hyperactive ones,

corresponding to the “insidious" onset traditionally associated with

schizophrenia (9).

Darrah, like Sullivan, used the two terms "dementia praecox"
and "schiz0phrenia" to distinguish the two forms, and agreed with
Sullivan in his description of dementia praecox as having an insidious
onset, progressing to deterioration, with a schizoid prepsychotic per-
sonality. Schizophrenia in Darrah‘s view has an abrupt onset with
a milder, nondeteriorating course, good prognosis, and a usually
adequate prepsychotic personality (13).

Wittman and Steinberg, in a study of fifty—nine life histories
of schizophrenic patients, found in about 50 percent of their cases
a life-long “shut-in” personality picture, present from earliest
childhood on. "The true schiz0phrenic . . . from early childhood
on shows the characteristically schizoid type of reaction sometimes
even in the face of benign environmental factors, that develops into
the regression characteristic of 'process schiz0phrenia'” (61, p. 815).
There is no Specific onset, "but rather the progressive deve10pment
of a type of personality reaction pattern" (61, p. 816). The other
cases were considered to be a "schizophreniform" disorder based
on environmental factors.

Bellak summarizes this and other work, concluding that schiz-
ophrenia is not one disease entity but a syndrome or reaction type
associated with a large number of etiological factors. These range

fromucompletely psychogenic through a continuum to completely

organic (4). The two polar types can be differentiated on the basis
of prognosis, and he argues for considering the two as different dis-
orders; there is Hat least a reasonable chance that a common out-
come speaks in favor of a more or less common root" (4, p. 404).
The favorable group has the characteristics, contrary to the tradi-
tional description of schizophrenia, of an acute onset, atypical (not
schizoid) prepsychotic personality, a precipitating factor, confusion,
and not the classic ”clear sensorium." Many of the phenomena can
be understood in terms of psychological dynamics, the outcome is
relatively good, and affect will be more or less adequate.

Some experimental work has been done in an effort to dif-
ferentiate these groups more clearly. Kantor, Wallner, and Winder
compared two groups of schiz0phrenics, classified as reactive or
process cases on the basis of history, as to whether they were di-
agnosed psychotic or nonpsychotic from the Rorschach (32). Their
reactive group corresponds to the good prognostic group, their proc-
ess cases to the poor prognostic group. They obtained these results:
the cases could be reliably differentiated into process and reactive
groups from history criteria, the reactive cases tending to be called
nonpsychotic from the Rorschach and the process cases psychotic
with this test. They consider these results "evidence that process

and reactive cases differ in their psychological-function characteristics"

9
(32, p. 162), and further evidence for the existence of these two dis-
tinct groups within the traditional category of schizophrenia.

Funkenstein and his associates have differentiated several
prognostic groups of schizophrenics on the basis of blood pressure,
psychological, and clinical reactions to epiniphrine and mecholyl,
these drugs acting as autonomic nervous system stimulants (23»26).
They describe seven reaction patterns to these drugs and state that
no diagnostic group falls entirely into any one pattern, with schizo-
phrenia being included in more of the patterns than any other, pro-
viding further evidence for the heterogeneous character of this group.
They found that the patients‘ prognoses with electric shock treat-
ment were more in accord with their autonomic patterns than with
their clinical diagnoses.

Funkenstein, Meadow, and others, in a further series of stud—
ies of schizophrenics, found a positive relationship between prognosis,
autonomic patterns, and the capacity for abstract thinking (45-47).
They delineate three main types of patients on the basis of these
studies. Type A, with very poor prognosis, shows a marked im-
pairment of abstract thinking. This group was most deteriorated,
with inappropriate affect, poorly organized delusions, and low physi-

ological reactivity following mecholyl. They consider this type to

10
be the group originally defined by Kraepelin as dementia praecox,
the true "process" schiz0phrenia.

Type B, an intermediate group, is characterized by a slightly
better but still not good prognosis, with little loss of abstraction.
This group includes the majority of psychotics in remission and
represents also the autonomic pattern of normals. Schizophrenics
of this type have highly organized delusional systems, less visible
anxiety than patients of the other groups, and are well preserved in
appearance.

Type C, the other polar type, has very good prognosis and
corresponds to the "reactive" schiz0phrenia category. This type
has a relatively intact capacity for abstraction and a strong physi-
ological reaction following mecholyl. Anxiety and turmoil are prom-
inent and there is a large emotional component, with often a depres-
sive coloring. Affect is usually appropriate, and the group shows
neither organized delusions nor deterioration.

These two polar types and the intermediate group correspond
to the three types of reaction described by Boisen (6). These in-
clude those patients who drift into the psychosis through a gradual
withdrawal, with no struggle; those who form delusional misinterpre-

tations (the well-systematized paranoids) enabling them to maintain

11

some integration; and those who react with panic and acute disturb-
ance, facing their problems and often recovering.

These studies give extensive evidence for at least two polar
types, with possible intermediate mixtures. Whether these groups
are completely different entities in terms of etiology and dynamics,
or are end—points on a continuum running from organic to psycho-
logical etiology, as Bellak suggests, the findings are important and

should be considered in the study of schizoPhrenia.

THE PROBLEM OF EMOTIONAL RESPONSIVENESS

One of the many problems in the study of schizOphrenia and
one that seems to have been particularly influenced by the lack of
recognition of the division behind the process-reactive distinction,
is the question of emotional withdrawal. In the classical description
of the disease the patient withdrew progressively from the world
until he lost all contact with reality. This withdrawal was accom-
panied by a change in affect which consisted of blunting and dis-
harmony of the emotions. The condition was further displayed in
the lack of interest, the indifference and apathy of the schizophrenic,
and especially in his marked lack of rapport with the social environ—
ment.

This concept has been criticized in regard to both the extent
and nature of the withdrawal. Thus, Sullivan believed that the schizo-
phrenic, being extremely sensitive to rejection and trauma, concealed
his true feelings by a suppression of interest and overt signs of emo-
tion: "the alleged indifference, apathy and emotional disharmony of
the schizophrenic patient are more a matter of impression than a

correct evaluation . . . of the patient" (57, p. 153).

12

13

Similarly, Lang, reporting his own experience as a schizo-
phrenic, attests to the presence of interests and feelings as strong
as before the onset of the psychosis, and gives a clue to the fate
of these responses: ”While the capacity for affective discharge
has continued with little abatement, there has been an increasing
tendency for affective discharges to be centered around ideation"
(38, p. 193).

Confronted with this contradiction, it seems well to look at
some of the experimental evidence on both sides of the question.
This evidence, besides illustrating the difference in opinion in re-
gard to the emotional responsiveness of the schizophrenic, also

demonstrates certain of the difficulties involved in work with this

group.

The Low Reactivity View

This line of thinking has been that the apathy is pervasive
and deep throughout the whole organism, a withdrawal at every level
possibly based on low physiological reactivity. This low reactivity
reduces the capacity for emotional response and effector action,
the patient no longer responding to stimuli that normally would evoke
a reaction. Angyal, Freeman, and Hoskins, basing their conclusions

on several physiolOgical studies, take this view and state that withdrawal

14
is the one common symptom among all the variety of schizophrenias
(2). They claim that this withdrawal is shown psychologically in the
indifference and apathy seen clinically; physiologically in such char-
acteristics as lower basal levels of the oxygen consumption rate,
blood pressure, and circulation time.

Other evidence in support of a low reactivity hypothesis is
provided by Angyal and Blackman in their finding of a reduced nystag-
mic response in schizoPhrenics (l). Vestibular reactivity was low,
part of the general decreased responsiveness of their group of pa-
tients. Similarly May found diminished pupillary responsiveness to
pain and light (44), and Pincus and Hoagland (51) found that schizo—
phrenics as a group showed adrenal cortices typically unresponsive
to stress and unable to alter action to meet changing environmental
demands. Freeman and Rodnick (21) reported blood pressure, heart
rate, and respiratory volume in response to the breathing of hot
Imoist air considerably less in schizophrenic patients than in normal
subjects; and in another study these same investigators found less
postrotational sway in schizOphrenics than in normals (22). Thus
there is considerable evidence for a profound withdrawal, affecting

even physiolOgical processes, in schizOphrenia.

15

The Normal or Excess Reactivity View

There has, however, been evidence contrary to the above find-
ings. Experimental results from other physiological studies support
the view that a good deal of responsiveness remains, even in chronic
patients. The results vary somewhat from study to study but in
general heightened physiological activity is found under stress, with
poor discrimination and a tendency to reach a high level of arousal,
or to overreact.

Thus Williams studied the psychogalvanic, respiratory, and
pulse rate responses of "early chronic'l schizOphrenics to several
psychological stress situations (60). His subjects showed a heightened
level of physiological activity (as compared to normals) during both
rest and stress periods. There was less arousal to the specific
stress situations, the high basal levels of response apparently mask—
ing more specific responses, and the group was further character-
ized by less recovery following stress.

Malmo and Shagass compared "early" schizophrenics with
neurotics, anxiety states, and normals, on several measurements of
physiological response. They found that the early schiz0phrenics
most resembled the anxiety patients in their greater responsiveness

and lower threshold of reaction, but showed a lack of discrimination

16
among the various stimulus intensities in their responses, a pattern
of poor discrimination and overresponse (41, 42).

In a similar study, Malmo, Shagass, and Smith found normal
and greater than normal background physiological activity under stress
in chronic schizophrenics. ”Purposive" overt acts were less fre—
quent in this group but tension levels were high. The authors hy-
pothesize that those aspects of responsiveness associated with emo-
tional arousal are intact in chronic schizophrenics, but the mechan-
isms underlying overt acts are inOperative (43).

Other data showing normal or greater than normal reactivity
on a physiological level include the results of D. E. Cameron (8) and
H. Freeman (20) on temperature regulation, and the study of Cohen
and Patterson (11) in which schizophrenics showed an abnormally
elevated pulse rate under painful stimulation. Similarly, Landis,
Hunt, and Page found a greater than normal startle response in
schizophrenics (37), and Freeman and Pathman found no difference
between normals and psychotics in the basal physiological activity
levels (19). These results lead to the view that at least normal
physiological responsiveness is present in schi20phrenics, if not
always manifested overtly. Hunt and Cofer, in their review, come
to this same conclusion, stating that "although no reduction of emo-

tional behavior at the reflex or autonomic level appears in

l7
schiz0phrenics, they show marked deviations from the normal

in overt behavior related to emotion" (29, p. 1002).

Summary of Studies of Responsiveness

While the variety of results summarized here may not all be
comparable, it still can be seen that there is a great deal of dis-
agreement and even flat contradiction. In general most investigators
agree that the chronic schizoPhrenic shows less overt responsiveness
than the normal or neurotic. This cannot, however, be generalized
to include all schizophrenics since several investigators report
heightened overt reactions in the acute stage. In terms of internal
or physiOIOgical response there is evidence fOr both lower and higher
reactivity than in the normal, and some studies have shown a normal
response. Commonly it is found that schizophrenics show poorer
discrimination and less tendency to react to specific experimental
stimuli, and less ability to vary response appropriately in terms

of the strength of the stimulus.

Shortcomings of These Studies

When the varying psychological and physiological features of
the two groups (reactive and process) discussed earlier are consid-

ered, it is apparent that experimental studies can be expected to

18
give contradictory results unless this factor is taken into account.
The diverse natures of these groups, as indicated in the studies of
Funkenstein (23-26) and Kantor, Wallner, and Winder (32), are such
that they could almost alone account for the inconsistency of the
findings on emotional responsiveness just reviewed. This factor has,
unfortunately, been almost entirely neglected in most of the work
done in the area, and deserves much closer attention in future work
of this kind.

Three other factors that could possibly contribute to the con—
fusion in this research on responsiveness are also due some atten—
tion. These factors are concerned with certain methodological features
of the experimental work, as well as the selection of subjects, and
“All be discussed in this order:

1. The disorder has been studied at different stages of its
developnnent.

2. The stimuli used have varied widely, and cannot always
be specified because of the effect of the illness itself on the subjects'
perceptions.

3. ldany dfiferenttypes ofrneasures of response have been

used.

19

Stage of schizOphrenia. The importance of the stage at which

 

the disorder is studied has been demonstrated by several investigat-
ors. Noted previously were the results of Malmo and his co-workers
who found increased reactivity at both overt and covert levels in
early schizophrenia but decreased overt response to the same stimuli
in chronic schizophrenics (41-43). Pfister, on the basis of studies of
pulse, blood pressure, body temperature, and skin irritability, de-
scribes three stages from “morbid hyperexcitability" to a stage of
"partial damage" to a final hypoactive state with a "complete loss
of autonomic regulation." In this process ''the very refined regulat-
ing mechanism shows first a weakening and finally a complete loss

of function" (50, p. 116). Collins makes the same sort of observa-
tion with regard to emotion, finding the affect of cases with a shorter
duration much stronger than the affect of chronic cases (12). It is
apparent that different investigators would be likely to arrive at in-
consistent results if they studied these different stages in the course

of s chi zophrenia.

Experimental stimuli. The experimental stimuli have varied

 

widely, from the interperSOnal stress of Williams (60) to pain pro-
duced by heat (41), loud noises (37), word association tests (12), and

others. This heterogeneity of stimuli limits the comparability of

20
one study with another, and the diversity of the results that have
been obtained attests to the danger of generalizing from a specific
situation. Uniformity of procedure among different investigators
and the use of several stimuli in any one study are needed, especially
stimuli that will arouse different levels of response.

In addition it is difficult to really Specify and control the
stimulus to which the schizophrenic is reacting, even when great
effort is made to do so. Sullivan mentions this problem and states
that the schizophrenic often reacts to his own rather than the ex-
perimenter's interpretation of the situation, because of his delusions
and intensely personal frame of reference (57). Hunt and Cofer
draw the same conclusion from their review of the literature:
arousal and response Operate in the schiz0phrenic but to his own
preoccupations and interpretations (29). Syz's (59) finding of many
spontaneous responses and Williams' (60) and Malmo's (41) results
showing a high general level of tension with a dearth of responses
to specific stimuli give more experimental support to this point of
view.

This type of misinterpretation can be considered a defect in
the set to respond, or a lack of ability to take the anticipatory set
demanded by the situation. If the prestress set of patients and con-

trols differs one can expect different results, and if the difference

21
lies in the fact that the situation has no meaning for the schizophrenic
then one would eXpect no response. "The problem is expanded from
the mere question of 'responsivity' to 'responsivity to what and how‘ "
(54, p. 676).

The studies of Rodnick (53) and Paintal (49) illustrate this
point. Both found that schiZOphrenics gave responses approximately
equal to those of normals to actual stress stimuli, but that the pre-
paratory responses to a "ready" signal of the schizophrenic groups
were only about one-half that of the normal groups. Both studies
used the psycho-galvanic technique, demonstrated by Furer and Hardy
(27) to be more a response to the threat content of a stimulus than
to the stimulus itself. This would indicate that results such as
Rodnick's and Paintal's are due to the failure of schiz0phrenics to
perceive certain stimuli as threatening, these stimuli ordinarily being
quite effective in producing a response in normals. Thus the defini-
tion of the stimulus in these studies is difficult since it may have

no meaning, or an entirely different meaning, for the schizophrenic.

Measures of response. The measures of responsiveness have

 

also varied a great deal. A few of those used, as reportedin the
studies mentioned above, include GSR, the pupillary reflex, oxygen

consumption rate, nystagmus, adrenal cortical hormone output, heart

22
rate, reSpiratory volume, and word association time. It can be seen
that there will be difficulties in interpreting the presence or absence
of all these different activities as representative of the same phe-
nomenon, withdrawal or responsiveness.

The mathematical expression of the measurements has also
been subject to much variation; included among them have been level,
latency and frequency of response, amount of change, and percentage
of the maximum response. Dunbar (15) stresses the importance of
the stability rather than the level or amplitude of a process to show
the presence of emotion. She states that it is not the level of the
equilibrium itself, but the change and the time required to return to
equilibrium that is significant. G. L. Freeman and his co-workers
have used this suggestion in their work and have found that the dif-
ferences in arousal and recovery time were an important differentiat-
ing characteristic between psychotic, neurotic, and normal groups

(17—18).

STATEMENT OF THE PROBLEM

The present problem concerns physiological re3ponsiveness in
reactive and in process schiz0phrenia, with an emphasis on the con-
trol of the factors just reviewed. These two groups of schizophrenics,

all in the chronic stage of the disorder, and a control group of nor-

mals we re studied.

Criteria for Reactive and Process Schizophrenia

The schizophrenic subjects were selected on the basis of case

history and clinical data to meet the criteria of reactive or process
The original list of criteria used in differentiating

schizophrenia.

the reactive and process groups was taken from several of the stud-

ies and reviews found in the literature. A list of these criteria

appears in Appendix I. For our purposes these criteria were re-

duced to the following four:

1. Prepsychotic personality: In the process group this meant
a prepsychotic personality of a schizoid type, characterized by se-
clusiveness, withdrawal, apathy, and indifference. The reactive group
includes those with a normal or neurotic, not schizoid, personality.

They had been more outgoing than the process cases, with some de-

gree of active social success.
23

24

2. Precipitating stress: Among the reactive cases there
was in each a significant precipitating stress or situation present,
one that logically could have precipitated the psychosis. The patients
in the process group had no particularly severe stress that could
have precipitated a psychotic break.

3. Onset: For the process group this was a continuous,
insidious, gradual development and exaggeration of the traits of the
prepsychotic personality, with no specific point at which a break
could have been said to occur. The reactive group had an abrupt,
acute, sudden, and stormy break with distinct changes in personality
and habits, leading into an acute episode.

4. Clinical picture: The acute episode of the reactive group
was marked by an exacerbation of the psychotic symptomatology,
especially the affective features, severe confusion, and hallucinations.
These patients had strong emotional outbursts with anxiety, turmoil,
and sometimes depression, and they were disoriented and clouded in
sensorium. The process group did not undergo this acute episode,
their affect appearing flat, inadequate, or absent, with little severe
disturbance. They were relatively well oriented, with a clear sen-
sorium.

Several of these criteria overlap to some extent; however,

they highlight the most important differentiating characteristics of

25
the two groups, and each points to some aspect of the history or
clinical record that could be judged with a certain degree of clear-
ness. The cases were judged, according to the criteria, as clearly
fitting one or the other category. A. difficulty arose in that because
of their better prOgnosis, one would not expect to find many chronic
cases of the reactive type, and the differences both in responsiveness
and clinical appearance at this stage may be smaller than in the
earlier stages, where the reactive schizOphrenic is more likely to
undergo an acute episode. Enough cases were found, however, to
make a sample and the differences in responsiveness were left to
the study.

Because of the results of Funkenstein (23-26) and Boisen's
description (6), it appeared that "well-organized" paranoids, those
‘that are stabilized with a relative lack of deterioration, could repre-
sent an intermediate1 group that might obscure the differences of the
extremes. For this reason an effort was made to exclude these
cases.

The symptoms (prepsychotic and onset) of the process group
Were in all cases present before the age of twenty years. The symp-
toms of the reactives did not appear until after this age, near the
time of the acute break and hospitalization.

¥

Intermediate in terms of physiological reactivity and dis-
turbance, as well as prognosis.

26

Stimuli

The reactions of these groups (process, reactive, and control)
to three different stimuli were measured. These three stimuli were
chosen to be quite different in nature, in order to tap different levels
of responsiveness: response to psychodynamic conflict or anxiety;
response to a present reality threat; and response on a startle level.

The first of these stimuli consisted of a set of four pictures,
one of neutral value and three which were selected because they rep-
resent common sources of anxiety: hostility, dependency, and sex.

These pictures were identical with the ones employed by Sines
(55), and were used because of their success in his study in arous-
ing autonomic responses of the same type that were measured here,
and especially because of their apparent value in tapping psychological
conflict in an experimental situation. The presentation used by Sines
was held to in this study, each card being placed in front of the
subject for a period of forty seconds. At the beginning of this time
a structuring statement was made in order to control as much as
possible the subject's interpretation of the picture. These statements
were also taken from Sines' procedure.

The first picture, a print of card 12BG of the TAT series (48),

was used as a neutral picture, one that would not in itself probably be

27
associated with any particular conflict. It was used because of the
likelihood of any stimulus giving a large response after the initial
rest period of the experimental session. The structuring statement
made was “Imagine yourself in a situation like this-~it's a nice sum—
mer day when you can relax and really take it easy."

The hostility picture, a drawing made especially for Sines'
study, was structured by "Put yourself in this fellow's position--
your feelings are breaking loose and you're going to do something
that you've wanted to do for a long time." The sexual card, a print
of a picture taken from Esquire magazine (16), was given this struc-
turing statement: "Put yourself in this man's position--you have
yourself all set up and whatever you do now is entirely up to you."
The dependency picture, card 6BM of the TAT, was presented with
the statement “Think of yourself as this kind of a fellow--a1ways
depending on your mother for help."

Copies of the pictures will be found in Appendix II.

A. second stimulus, a startle stimulus, was made up of three
doorbells mounted on a piece of sheet metal. This gave a loud
harsh noise, the bells being rung simultaneously for the time of
three seconds. This device was used to elicit a response at a re-
flex level, giving less chance for distortion by the schizophrenics

and being almost certain to draw a response from all subjects.

28
The third stimulus, a verbal warning, was given at least thirty
seconds before the presentation of the bell. The warning was: "In
a moment I am going to ring a loud bell. Relax and listen for the
bell.” This warning was used for two reasons: because of the pos-
sibility of differences in the preparation to respond to threat between
the three groups, and because it did not seem wise to subject psy—
chotic patients to such a jarring stimulus as the bell with no warning

b efo rehand.

Responses

Two related but different reactions, GSR and heart rate, were
used as indexes of physi010gica1 response. These reactions were re-
corded by means of a polygraph. The instrument used in this study
was the Multi-Channel Recorder No. 603, constructed by the Lafay-
ette Instrument Company. This polygraph records the three indexes
of autonomic activity, change in heart rate, respiration, and the
galvanic skin response (GSR) commonly obtained with this type of
device.

GSR was taken by means of finger electrodes attached to the
index and third fingers of the right hand of the subject. Contact was
aided by means of a standard electrode paste. Heart rate was re—

corded with a standard blood-pressure cuff, which in this study was

2-9
placed just below the knee on the subject's left leg. The leg was
used because the blood-pressure cuff, when placed on the arm and
inflated, produces considerable discomfort after a very short time.
The cuff can, however, be kept on the leg for periods of at least
twenty to thirty minutes with no more than a very slight sensation
of numbness in the foot. Respiration was also recorded, by means
of a pneumograph placed around the subject's chest. This measure,
however, was discarded before analysis of the data because on in-
spection of the records as obtained, it appeared rather unreliable
and erratic, due to mechanical difficulties in the recording apparatus.

The question arises as to what kind of state is actually being
measured by this instrument. The activity recorded was considered
primarily an index of "responsiveness" or "reactivity," rather than
"apprehension," "alertness," "preparedness to react," or "anxiety."
The term "responsiveness" seemed to give a simpler and less sug-

gestible label for the condition involved.

Hypothe s e s

Reactive and process schizophrenia, as discussed in the lit-
erature, present differences in development which lead to contrasting
Clinical patterns after the patients have definitely become psychotic.

These contrasts are found especially in levels of activity: the process

30
schizoPhrenics are hypoactive with symptoms of apathy and lack of
strong emotional response, and the reactives tend more towards
hyperactivity and rather extreme manifestations of emotion. These
varying patterns suggest possible basic differences in terms of phys-
iological response, the assumption being made here that autonomic-
ally activated physiological responses can be used as valid indexes
of emotional states. The two groups would then differ in physiologi—
cal response, with the reactive group more likely to show a higher
level of activation than the process group. The first three hypotheses
were made on this basis, each with regard to a different measurable
aspect of response. These hypotheses are:

1. Base levels. The background levels of physiological
activity were recorded, with the subject at rest, as free as possible
from any external stimulation. It was expected that the reactive
group would show higher levels of basal activity than the process
group.

2. Amplitude of reSponse. It was hypothesized that the am-
plitude of specific responses to the experimental stimuli of the re-
actives would be larger than those of the process patients.

3. Arousal and recovery times. The expectation was that
the reactive group would take longer to reach a peak of reSponse,

and longer to recover, than the process group.

31

The last hypothesis was based on the studies of Rodnick (53)
and Paintal (49), and was intended as a check on differences among
the groups in the set a) respond to a threatening sthnulus.

4. Reaction to a preparatory stimulus, the verbal warning.
The response of the normals to the warning was predicted greater
than the response of the schizophrenics, and it was expected that
the reactives would produce a larger response here than the proc-

ess group.

METHODOLOGY
Subjects

The subjects included two groups of hospitalized male veter-
ans, eighteen in each group, and also a group of eighteen normal
control subjects, all veterans. The two groups of schizophrenic
subjects were matched individually for age and length of hospitaliza-
tion and the control subjects were- matched with the schizoPhrenics
for age. The ranges and means of age and hospitalization appear
in Table I.

All the schizophrenics had been hospitalized for at least six
years, placing them in the late chronic stage of the disorder. All
of them had been diagnosed schizophrenic on admission to the hos-
pital and at least once thereafter, at a routine periodic review by
a board of three psychiatrists.

Only those cases were selected where there was no question
of mental deficiency by the examining psychiatrists. It would have
been desirable to have an estimate of 1.0. on all the patient group,
but their clinical condition made the administration of tests difficult
if not impossible. Since the reactions studied were physiological
and no verbal or other voluntary responses were required, it was

32

33

TABLE I

AGE AND LENGTH OF HOSPITALIZATION

 

 

 

Item Reactive Process Control
Age range ................. 28-47 27-48 26-49
Mean age .................. 37.1 36.7 36.7
Range of hospitalization ........ 6-11 6-12
Mean years of hospitalization . . . . 8.7 8.8

 

 

assumed that the psychiatrists‘ judgment would be adequate to con-
trol this variable.

The subcategories of the patients‘ diagnoses are shown in
Table 11. As will be seen in the table, there were no cases of
schiZOphrenia, simple type, in the reactive group, and no paranoids
or catatonics in the process group. These subdiagnoses were not
included in the criteria differentiating the two groups; the cases,
after being placed in their respective groups, were then found to
show this characteristic.

The control subjects were all selected from hospital person-
nel. None had ever had a history of neur0psychiatric disorder of
any kind. The sample included office workers, physical therapists,

and several social workers and psychologists.

34

TABLE II

PA TIENTS' SUBDIAGNOSES

 

 

 

Subtype Reactive Process
Simple .......................... O 2
Catatonic ........................ 3 O
Paranoid ........................ 5 0
Hebephrenic ...................... 5 7
Mixed .......................... 2 3
Unclassified ...................... 3 6

 

 

Because of the procedural problems involved in subjecting
schizophrenic patients with this degree of disturbance to extensive
measurements and stimuli, preliminary interviews were made with
all prospective patient subjects (after they had been separated into
the two groups). These interviews were done to ascertain whether
or not the patient was accessible enough to cooperate in the study
itself. All subjects were taken from one ward in the hospital, in

order to keep the degree of disturbance as constant as possible.

35

Measures

The two measures used, heart rate and GSR, were recorded
both at rest and during stimulation. Heart rate was taken as simply
the frequency per minute, basal heart rate levels being obtained
from the mean frequency during five minutes of rest preceding the
presentation of the first stimulus.

Basal GSR was taken just before presentation of the first
stimulus, following the rest period during which the skin resistance
was allowed to stabilize. This rest period was kept at least five
minutes in length, to obtain the base heart rate; when GSR failed
to reach a stable level during this time the period was continued as
long as necessary. In most cases this was within ten minutes; with
two subjects the period had to be extended as long as twenty min-
utes. In any case, the basal heart rate was measured from the
last five minutes of the rest period.

GSR deflections after stimulation were recorded on the kymo-
graph chart. In order to give a reading in ohms for each deflection,
the galvanometer was calibrated by means of a standard decade re-
sistance box. The galvanometer, in this procedure, was set at the
level of sensitivity used for all subjects, and curves were graphed

using base resistances from 5,000 to 150,000 ohms in 5,000-ohm steps.

36
Deflections of 100 ohms, to the limit of the chart, were recorded
at each base level, and the graphed reactions of the subjects were
measured against these deflections.

The final unit used for GSR was conductance, the resistance
readings in ohms (R) being converted into conductance units in
microhms (C) by means of the formula

1 6
C = 3(10 ).

It has been demonstrated (35, 36) that only conductance and
log conductance units of GSR are independent of the base level of
skin resistance, and give scores which do not deviate significantly
from normality. For this reason one of these two measures seemed
best suited for use in this study; conductance was chosen because of
its greater arithmetical convenience.

In addition to this measure of amplitude of response, the
length of time after stimulation for the GSR to reach a peak (arousal)
and the time to return to the base level (recovery) were also re-
corded. This was done to give an indication of the stability of re-

sponse.
Procedure

Each subject, before being brought into the experimental sit-

uation, was told that measurements would be made of his pulse rate,

37
breathing, and how much he perspired. The patients were also told
that the measurements were part of a routine checkup, to determine
the general condition of their health. Any questions of the subject
were answered at this time.

The subject was then brought into the room and seated in an
armchair, his right arm placed on a table with the hand on a sponge-
rubber pad to reduce movement, and the finger electrodes were at-
tached. The left leg with the blood pressure cuff attached was placed
on another sponge-rubber pad, lying on a chair and supporting the
thigh and foot of the subject, thus keeping his leg in a comfortable
position. The subject was requested to relax and to try to move as
little as possible, and not to speak. During the preliminary rest
period he was asked to close his eyes.

Each subject was seen for two sessions: in the first session
he was placed in the apparatus, which was then turned on for a few
minutes. This was done to familiarize him with the situation and
to alleviate any anxiety produced by the rather complicated and
strange-appearing equipment.

The actual experimental work was done in the second session.
The procedure in this session began with the usual instructions and
adjustments of the equipment, after which recordings were made with

the subject at rest, in order to obtain base level records. At the

38
end of at least five minutes, or longer if needed for the skin resis-
tance to reach a stable level, the subject was told: "I am going to
show you some pictures. You don‘t have to do or say anything, just
look at the pictures when I show them to you and try to remain as
quiet as possible." These instructions generally were followed by
a change in the skin resistance; after the resistance had returned
to the base level, the Neutral card was presented, with the struc-
turing statement made at the beginning of the presentation. The
picture was held in front of the subject for a period of forty sec-
onds and then removed. The skin resistance was again allowed to
stabilize. After this had occurred, and never before three minutes
had elapsed, the next card was presented, the same procedure being
used.

At the conclusion of the presentation of the pictures, the
blood pressure cuff was deflated and the subject allowed to relax
and talk for a few minutes. The cuff was then reinflated, and when
the base skin resistance had been established the verbal warning
was given. At the end of thirty seconds, or longer if necessary to
stabilize the GSR curve, the bell was rung for three seconds. The
subject was then allowed to relax for a period of at least five min-
utes, with the recordings being continuously made, before being

taken out of the apparatus.

39
All but a few of the subjects were very c00perative and made
every effort to remain quiet throughout the session. The exceptions
were several schizOphrenics who began to hallucinate during the pe-
riod, with subsequent verbalization in response to the hallucinations.
When this occurred, the presentation of stimuli was stopped and the
patient was asked to try to relax and be as quiet as possible for a
few minutes. Eventually all of these subjects were able to stop their

overt response to the hallucinations, and the session was then con—

tinued.

RESULTS

The results are presented in the same order as the four hy-
potheses, which were discussed in the "Statement of the Problem."

1. Base levels. Base or resting levels of heart rate were
taken as the mean frequency per minute of the five minutes prior
to the presentation of the first stimuli, the pictures. The mean
base heart rate of each group, the differences between group means,
and tests of the significance of these differences appear in Table III.

As will be seen in the table, the reactive group had a basal
level of heart rate significantly greater than the basal level of either
the process or control groups. The difference between the base lev-
els of the latter two groups was small and not significant, their mean
rates during the resting period being almost identical.

All of the differences between the three groups in terms of
basal GSR were small, and none of these differences was statistically
significant.

2. Amplitude of response. The amplitude of response in
terms of heart rate was taken as the difference between the mean
rate of the five-minute rest period and the mean rate per minute of

a two-minute period immediately following the presentation of each

40

41
TABLE III

HEART RATE BASE LEVELS, DIFFERENCES BETWEEN
GROUPS, AND T-RATIOSI

 

 

 

Groups D t
Reactive (92.2) - Process (82.1) .............. 10.1 4.81
Reactive (92.2) - Control (81.5) .............. 10.7 5.94
Process (82.1) - Control (81.5) .............. 0.6 0.23

 

 

A t-ratio greater than 2.90 is significant at the 0.01 level
of confidence.

stimulus. Because there was not always a long enough time follow-
ing the verbal warning and before the bell to give a reliable estimate
Of the change in this measure after the warning, these two stimuli
were combined to give a single stress measure. The mean change
in heart rate was calculated from the average rate Of a three—minute
period beginning with the warning and continuing in all cases for at
least two minutes after the bell. The average response of each
group after each stimulus for this measure is Shown in Table IV,
and the differences between groups and tests of Significance Of these
differences appear in Table V, under the heading "Heart Rate-Am-

plitude . "

TABLE IV

MEANS OF EACH GROUP FOR ALL MEASURES OF
REACTIVITY AND STIMULI

42

 

 

 

 

 

 

Stimuli Reactive Process Control
Heart Rate-Amplitude
Neutral ................... 1.18 - 3.15 2.34
Hostility .................. 2.52 - 1.91 2.73
Dependency ................ 2.38 - 2.72 2.23
Sex ...................... 2.56 - 2.12 0.56
Warning ................... ’3‘ ' * *
Bell ..................... 0.70 - 2.65 - 0.93
GSR-Amplitude
Neutral ................... 1.85 0.98 2.28
Hostility .................. 2.01 0.91 2.09
Dependency ................ 1.36 0.57 1.59
Sex ...................... 2.21 0.92 3.41
Warmng ................... 0.77 0.46 2.03
Bell ..................... 2.19 1.08 3.25
GSR-Recovery

Neutral ................... 66.6 39.0 31.6
Hostility .................. 76.8 39.8 26.4
Dependency ................ 49.3 13.9 16.4
Sex ...................... 73.1 42.9 55.9
Warning ................... 36.1 12.2 20.2
Bell ..................... 74.4 38.9 44.3

 

 

* Mean changes in heart rate during a three-minute period
beginning with the warning and continuing for at least two minutes
after the bell are presented in this table after "Bell."

TABLE V

43

DIFFERENCES AND SIGNIFICANT T-RATIOS BETWEEN GROUP

MEANS ON MEASURES OF REACTIVITYl

 

 

 

 

 

 

 

 

 

Reactive- Reactive- Control-
, , Process Control Process
Stimuli

D t D t D t

Heart Rate-Amplitude
Neutral ...... 4.33 4.98 - 1.16 5.49 7.04
Hostility ..... 4.43 4.76 - 0.21 4.64 5.10
Dependency 5.10 6.30 0.15 4.95 5.32
Sex ......... 4.68 4.22 2.00 2.68 3.78
Warning ......
Bell ........ 3.35 3.72 1.63 1.72

GSR-Amplitude
Neutral . . 0.87 2.18 0.43 1.30 3.28
Hostility ..... 1.10 2.40 0.08 1.18 2.74
Dependency 0.79 2.14 0.23 1.02 2.68
Sex ......... 1.29 2.48 1.20 2.49 4.37
Warning ...... 0.31 1.26 2.68 1.57 3.20
Bell 1.11 2.54 1.06 2.17 4.34
GSR-Recovery

Neutral ...... 27.6 2.24 35.0 2.50 7.4
Hostility ..... 37.0 2.31 50.4 2.71 -13.4
Dependency . . . 35.4 2.79 32.9 2.61 2.5
Sex ......... 30.2 2.12 17.2 13.0
Warning ...... 23.9 15.9 8.0
Bell ........ 35.5 3.82 30.1 3.16 5.4

 

 

1
A t greater than 2.11 is significant at the 0.05 level; a t
greater than 2.90 is significant at the 0.01 level; t-ratios not sig-

nificant at 0.05 or 0.01 levels are not included in this table.

44

The reactive group of schizophrenics gave a significantly
greater positive change to all stimuli than the process group, but
there were no Significant differences between reactive and control
groups. The normal controls showed a significantly larger response,
in terms Of a positive heart rate change, to the pictures than did the
process group, but the difference of the two groups on the warning
and bell combination was not large enough to reach statistical Sig-
nificance.

The difference in microhms between the peak of the GSR
curve after stimulation and the base GSR before stimulation was
used as the amplitude of this response. The means of the three
groups for this measure are Shown in Table IV, under "GSR-
Amplitude." The differences between groups and tests of signifi—
cance will be found in Table V under the same heading. An exam-
ination of the group means reveals that the process group gave a
smaller, and the normal controls a larger GSR than the reactives on
all stimuli. The reactive group gave a significantly greater GSR
than the process group on all stimuli except the warning; the dif-
ference here was not large enough to reach significance. There
were, in turn, no significant differences between the controls and
the reactives except at the verbal warning, where the normal con-

trol group responded with a significantly larger GSR than the reactives.

45
The controls gave significantly larger responses than the process
schizophrenics after all stimuli.

3. Arousal and recovery time. There were no consistent
significant differences between any of the groups in time of arousal
of the GSR to a peak. The group means for recovery time are given
in Table IV, and the differences between the groups and the tests of
significance in Table IV, both under the heading "GSR—Recovery."

The reactive group Showed significantly longer times to re—
cover from the peak GSR than the process group after all stimuli
except the warning. The differences after the stimuli between the
reactives and normals were also all significant with the exception
Of the warning and sex card stimuli, the reactives taking longer to
recover. There were no significant differences between the recov—
ery times of the normal and process groups.

4. Reaction to a preparatory stimulus, the verbal warning.
The response of the normals, in terms of amplitude of GSR, to the
verbal warning was significantly greater than the response of the
reactives or the process group. The difference between the two
schiz0phrenic groups was not large enough to reach statistical sig-
nificance. There were no Significant differences between any Of the
groups in either arousal or recovery time after the preparatory

stimulus.

DISCUSSION

These results give evidence for the hypothesis that within the
older classification of schizophrenia there are at least two main
groups, distinct from the traditional subtypes of the disorder. These
groups, in this study called reactive and process, were originally
differentiated on the basis of prepsychotic personality and the clin-
ical picture. Each was characterized by its own pattern Of physio-
lOgical reaction. Neither group gave a pattern of response similar
to that of a normal control group.

The reactive schizoPhrenics on the one measure, heart rate,
Showed a much higher base level than the other groups. The reac-
tives responded at about a normal level in amplitude of response tO
both the pictures and the bell, but gave a response well below the
normal, on GSR, to a verbal warning. Their recovery time on GSR
was slower than that of the other groups.

The process schiZOphrenics were characterized by a basal
heart rate similar to the normal. In amplitude Of the heart rate
response the mean changes Of this group were all negative and sig-
nificantly different from the changes of the other groups, which were

all positive with the exception of a slowing of the rate for the

46

47
normals after the warning and bell. The process schizophrenics
consistently gave a smaller GSR than the other groups to all stim-
uli, and showed a recovery time similar to the normal recovery

time.

Interpretation of the ReSponse Pattern: Reactive Group

The high base level of heart rate in the reactive group is
similar to the resting rates of the "early chronic schiz0phrenics"
found by Williams (60) and the levels of response of the ”early
schizOphrenics" found by Malmo and Shagass (42). This leads one
to suspect a sort Of chronic overresponsiveness still present in the
reactive group after years of hospitalization which could be a resid-
ual Of the original psychological disturbance and intense anxiety that
led into the acute stage of the psychosis.

The reactives in spite of this higher base level also evidenced
an increase in heart rate as large as the increase Of the normals
after the pictures. To further support the supposition of over-
responsiveness the reactives, while giving a response in amplitude
of GSR at about a normal level, took on the whole a significantly
longer time to recover on this measure than the normal group.

This seems to be an indication Of tension levels as high or higher

than those Of the normals with probably more difficulty in dissipating

48
the tension than normal. Certainly the capacity to be aroused is
still intact in the reactive group, and in some respects this arousal
to respond is considerably greater than normal.

Darrow, in a review of studies concerned with physiological
reaction to sensory and ideational stimuli (14), concludes that the
reflex response to momentary sensory stimulation is quite differ-
ent from the response to ideas aroused by the stimulus. The sen-
sory stimulus itself is more apt to excite peripheral responses, the
ideas more effective in increasing the activity of the heart. His
review, and the evidence of more recent studies (30, 31) indicate
that the sensory stimulus is likely to slow the heart rate, although
Darrow qualifies this'by adding that fright or startle after sensory
stimuli may momentarily increase the pulse, preceding the charac-
teristic Slowing.

If one accepfs Darrow's generalizations, the positive change
in pulse rate of the reactive group to the bell, where ordinarily a
negative change (a decrease in heart rate) would occur could indicate
considerable internal activity aroused by the bell, this stimulus hav-
ing a more ideational value for the reactives than for the other two
groups. Part of this ideation could be due to the verbal warning,

but this would still indicate a lower threshold to respond in terms

of ideation, for the reactive schizophrenics, since the other groups

49
also had the warning and still responded to the combination Of warn-
ing and bell with a decrease in pulse. The increase of the reactives
on this measure could also have been due to their being more star-
tled or frightened by the bell, again assuming Darrow's conclusions.
In any case there is evidence here for a greater responsiveness, in
some ways, possibly because of overideation or a lower threshold
for anxiety or fright, in the reactive group Of schizophrenics.

Nevertheless, the small GSR given by this group to the ver-
bal warning indicates a lack of responsiveness in other respects.
This particular instance of underreactivity (when compared to the
normal GSR to the warning) may have been a result of distorted
perception, a lack of contact with or realistic appraisal of the situ-
ation. The pattern of poor reality discrimination combined with
sizable reactions and a low threshold of response is similar to that
found by Malmo and his co-workers (41-43), and their suggestion
that part Of the high general responsiveness Of the schizophrenic
may be due to determinants not related to the external Situation is
substantiated to some extent by the previously discussed heart rate

reSponse of the reactive group to the warning and bell.

50

Interpretation of the Response Pattern: Process Group

The process schizoPhrenics, on the other hand, gave no indi-
cation Of a general level Of responsiveness or tension greater than
the normal. Their base level heart rate was almost the same as
that of the normal group, and significantly below the rate of the
reactives. Their GSR recovery times were also about normal, and
again, smaller than those of the reactives, although the shorter re-
covery times in this group could be due in part to the smaller
amplitude of their GSR: they had less to recover from in re-
establishing an equilibrium. The amplitude of their average GSR,
much smaller than that of the normal or reactive groups, also in-
dicates a lower responsiveness, and it would appear that this group
might be the hyporeactive group, with a possibly defective capacity
to respond.

The hyporeactivity was not complete, however. The process
schiz0phrenics did respond, but in a different way than the normals
or reactives, with a negative change in heart rate after all the stim-
uli. This response, according to Darrow usually found after sensory
stimuli, was often as large or larger than the positive changes in
heart rate given by the normals and reactives. In one instance, the

warning and bell combination, where a negative change might have

51
been expected and was found to occur in the normal group, the neg-
ative change of the process group was significantly larger than that
of the normals, giving an indication of a stronger than normal re-
sponse on this occasion.

From this it would appear that there was perhaps less ten-
dency to react with ideation, or possibly a higher threshold for fright
or anxiety, in the process group. Their GSR after the warning was,
like that of the reactive group, significantly smaller than normal,
showing a similar poor capacity to judge or respond to a reality
situation; but their lower GSR after other stimuli and their negative
heart rate changes evidence a lack Of responsiveness of a type that
the reactives still have.

The reSponsiveness still present in the process group could
be interpreted as occurring only at a reflex level, stimuli having
little value in producing ideation or as social stimuli. The basis
of this condition is problematical. The evidence only suggests a
restricted reactivity with a still adequate response at some levels

and to certain stimuli.

General Considerations Concerning Responsiveness

In any event there is responsiveness left in certain types of

chronic schizophrenics, even those that are sometimes considered

52
"burned-Out" or "vegetative." It is also evident that there is a
withdrawal, possibly varying in depth and quality, but nevertheless
there. The problem seems to be what kind of withdrawal, at what
level, and by what mechanisms?

Both Of the schizophrenic groups studied very obviously man-
ifest withdrawal at an overt level Of activity. The majority of the
patients in both groups are SO-called "Sitters." They eat and sleep
and little else. The two groups also showed a similar withdrawal
in this study, in their low response to the verbal warning. This
type of unresponsiveness seems to be at a deeper level than the lack
of overt activity mentioned above, being of an involuntary activity,
and can probably best be explained by the distorted relationship to
reality, or the loss of contact with reality, apparently found in both
groups of schizophrenics. Thus both groups Show a lack of response
at these levels.

The reactive schizophrenics, however, responded to most of
the other stimuli and were in fact quite strongly affected by them.
This could be due to a higher level of tension produced by still-
remaining psychOIOgical conflict, the reactives being preoccupied in
certain areas of dynamic importance and so responding to stimuli

that touch on these areas, to the exclusion of other stimuli. A new

53
realistic threat would not be effective in arousing them, but some-
thing touching on the Old threat would be.

The withdrawal of the process group seems to go much fur-
ther than this, their responsiveness being confined to the typical
reaction to sensory stimuli. This was given even at the presenta-
tion of normally ideation-producing stimuli.

Thus it can be seen that withdrawal, and the capacity to re—
spond, are not Simple variables. The control of the stimulus and
the definition Of the response are of primary importance in these
questions. The consideration of subjects having superficial Simi-
larities but deeper differences as one homogeneous group can espe-
cially cloud the picture, and it has been the essential purpose of
this research to show that at least two such groups can be differ-
entiated in the traditional classification of schizophrenia. These
two groups, in Spite of their similarities at some levels of symp-
tomatOIOgy, can be distinguished by history, early clinical appearance,
physiological response, and perhaps prognosis, and would appear to
provide a more meaningful basis for classifying schizophrenia than

the original four subtypes.

IMPLICATIONS FOR FURTHER RESEARCH

The problem of defining the stimulus was again brought out
in the results Of this research, and it was by no means settled here.
This difficulty was evident in the unexpected responses Of the schizo-
phrenics, especially the slowing-up of heart rate of the process
group after the pictures and the increase in heart rate by the re-
actives after the bell, indicating a much different value of these
stimuli for these groups than for the normals. Studies of percep-
tion, to determine the type of distortion and the effectiveness of dif-
ferent stimuli in well-defined clinical groups, could do much to clear
up this confusion.

The need for a precise answer to the question "Responsivity
to what, and how?" is shown not only in this difficulty with the stim- -
ulus, but also on the response level. That a difference in stimulus
meaning for different groups will produce a different type of re-
sponse is evident, but there are further unanswered questions about
the nature and meaning of a particular reaction itself. One can ap-
parently not find a reaction that will serve as a general index Of
responsiveness or tension or anxiety; study with more measures,

both of overt activity and physiological response, their interrelationships

54

55
and their significance at different levels will be necessary. Included
in this type of research should be the study of differences in individ-
ual physiological patterning. The work Of Lacey (33, 34) indicates
the probability Of a consistently varying emphasis On different re-
sponse systems for different individuals, some reacting for example
more with GSR, others with heart rate or another system. This
would seem to be an important variable in itself and its neglect
could well be an obscuring factor in research with clinical groups.

In regard to the particular groups studied in this research,
one question that can be raised concerns the adequacy of the cri-
teria used in their selection. Are all of these criteria relevant,
which are not important, and are there others which could better
differentiate the groups? The subtypes of schizophrenia might give
a clue here. AS shown in Table 11, there was some degree Of dif-
ference between the reactive and process groups, the former includ-
ing patients diagnosed catatonic and paranoid, the latter with no cata-
tonics or paranoids but two patients with a diagnosis Of schiz0phrenia,
simple type. Thus these two larger groups might also provide a
more comprehensive differentiation than the Older subtypes.

The physiological differences could possibly be brought out
more clearly in studies with patients having a shorter length of

hospitalization, and especially with patients in an acute stage or

56
episode. The Rorschach findings Of Kantor, Wallner, and Winder
(32) indicate that differences could be elaborated by means of psycho-
diagnostic work, and perhaps differences on other tests than the
Rorschach would be found.

There is also the possibility of other groups, especially the
"well—preserved" paranoids, giving Significantly different patterns
of response than the two groups used here, and studies of prognosis
would be an important practical application of the differentiation.
The schizophrenics in this study were chosen to represent
extremes in terms of develoPment Of the psychosis, and it would
seem possible that with these different developments there could
be basically different etiologies, one group perhaps psychogenic and
the other organic. These results give no evidence in regard to such
a difference in etiology, but the added clarity in definition of groups

should make the study of this question more rewarding.

SU MMAR Y

The nature of schizophrenia as a disease entity has been very
controversial, there being considerable disagreement in regard to
both diagnosis and symptomatology. The question of emotional re-
sponse and withdrawal has been especially subject to disagreement
and contradiction, theoretically and in the results obtained from in-
vestigation of the problem. Most investigators have reported less
overt responsiveness in the schizophrenic than in the normal or
neurotic, although heightened overt reactions have been found in
some cases. There has been evidence for physiological responsive—
ness less than, equal to, and greater than that of the normal. In
general deficiencies in discrimination among specific stimuli and
less ability to respond appr0priately have been noted.

The inconsistency of these results may be due to methodo-
logical features Of the experimental work and also to the selection
of subjects and the definition of the groups used. Four main factors
are evident here:

1. The possibility of the heterogeneous character of schizo-

phrenia itself.

2. The stage at which the disorder is studied.

57

58

3. The type of stimulus used and the change in value of the
stimulus resulting from the effects of the disorder itself on the sub-
jects' perceptions.

4. The measure of re5ponse.

The first variable was taken as the focus of this research,
although an attempt was made to control the others as much as pos-
Sible.

Two groups of chronic schizophrenics, eighteen in each group,
and a group of eighteen normal subjects, were studied. The schizo-
phrenics were differentiated into the two groups on the basis of case
history and clinical criteria, these groups being named "process"
and "reactive." The criteria included: (1) prepsychotic personality;
(2) precipitating stress; (3) onset; and (4) clinical picture.

Two types Of stimuli were used. The first was a set of four
pictures, one of probably neutral value and three which were selected
to represent common areas of psychological conflict: hostility, de-
pendency, and sex. The second stimulus consisted Of three doorbells
mounted on a piece of Sheet metal, employed to give a startle stim-
ulus. A verbal warning was given before the bell.

The re5ponses measured were base levels of heart rate and
GSR; heart rate and GSR change to the stimuli; and arousal and re-

covery time of the GSR to the stimuli.

59

The specific aspects of these responses considered included:
(1) background or resting levels of response; (2) amplitude of the
change in response; (3) arousal and recovery time of the GSR; (4)
differences in response to the verbal warning, a preparatory stimu-
lus, by the three groups.

The results of the study were as follows. The reactive
group of schizophrenics, on one measure, heart rate, showed a Sig-
nificantly higher base or resting level than either the normals or
process schiZOphrenics. There were no Significant differences be-
tween the groups On resting GSR. The reactives responded at about
a normal level in terms of amplitude of response, with both heart
rate and GSR, to both the pictures and bell, but gave a response
well below the normal to the verbal warning and on GSR showed a
definite tendency toward slower recovery than either the process or
normal groups.

The process schizophrenics were characterized by a consis-
tently smaller GSR-amplitude to all stimuli than the other groups,
including a significantly smaller response than the normals after
the verbal warning. In terms of amplitude Of the heart rate response,
the mean changes Of this group were all negative, being significantly
different from the changes in heart rate of the other groups which

were all positive with the exception of a slowing up of the rate for

60
the normals after the bell. The process group also took a much
shorter time to recover (on GSR) than the reactives, showing usually
a recovery time similar to that of the normals.

These results were interpreted to mean, primarily, that at
least two groups, defined on the basis of case history and clinical
criteria, and differing in physiological response to certain stimuli,
can be distinguished within the traditional classification of schizo—
phrenia. These groups do not seem to be independent of the tradi-
tional subtypes. Both groups manifest withdrawal at a social level,
and in terms of overt activity. Both are apparently relatively un-
responsive to a present environmental threat. The groups differ,
however, in the extent of the withdrawal. The reactive schizophrenics
were affected by most other stimuli and responded quite strongly to
them, their response reaching a normal level and in one respect,
recovery time, exceeding the normal level. The withdrawal of the
process group seemed to go much further, their responsiveness, in
this study, being confined to what seems to be a reflex response to
sensory stimuli, and in general being on a reduced level.

These results further emphasize the complex nature of such
concepts as withdrawal and responsiveness, and point to the need
for precise control of the stimulus and reSponse and to careful

definition of the subjects for study, in research Of this kind. They

61

especially indicate a more significant basis for classifying schizo-
phrenia than the traditional four subtypes. The reactive-process

distinction provides a differentiation meaningful in terms of etiology,

treatment, and prognosis.

10.

11.

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APPENDIX I

The criteria for reactive and process schiZOphrenic groups,
drawn from several of the studies in the literature (4, 6, 9, 13, 23-

26, 32, 45-47, 56, 58, 61).

 

 

Process

R eac tiv e

 

Prepsychotic personality:

Basic and constitutional se-
clusive makeup--schizoid per-
sonality. Psychosis more the
deve10pment and exaggeration
Of a personality type. Traits
present from early childhood,
withdrawn, seclusive,

 

including:
shy, apathetic, dreamy, listless,
indecisive, hazy, reticent, dis-
interested, poor attention and
concentration, oversensitive,
lacks initiative, lethargic, few
interests, hard to influence,
stubborn in a passive way, un-
communicative, lack of out-
standing defensive personality
traits.

Other criteria:

Early psychological trauma;
physical illness, severe or long;
"Odd" member of family; dif—
ficulties at school; family
troubles paralleled with sudden
changes in patient's behavior;
introverted; history of break-
down Of social, physical, men-
tal functioning; pathological
siblings; overprotective or

 

Atypical (not schizoid) person-
ality--adequate, normal, or
possibly neurotic.

Absence or minimal degree of
these traits.

Good psychological history--
absence of severe trauma; good
physical health; normal mem-
ber of family; well adjusted at
school; domestic troubles unac-
companied by behavior disrup-
tions--patient "had what it
took"; extroverted behavior
trends and interests; history of
adequate social, physical, mental

 

68

69

APPENDIX I (Continued)

 

 

Process

Reactive

 

rejecting mother--"momism";
rejecting father; lack of hetero-
sexuality; physical aggression;
little capacity for alcohol; fail-
ure under adversity; descrep-
ancy between ability and
achievement; clash between cul-
ture and environment.

Onset and early symptoms:

Insidious, gradual onset with-
out pertinent stress--or no spe-
cific Onset. DevelOps during
adolescence. A continuous de-
velopment and exaggeration of
prepsychotic traits.

Becomes more seclusive;
daydreaming; preoccupied; loss
of friends; irritability; loss of
interest and ambition; depressed;

 

 

lack of energy and concentra-
tion; fatigue; poor appetite.

These symptoms are closely
related to the prepsychotic per-
sonality; they are usually pres-
ent much longer before hospital-
ization than the early symptoms
of the reactive group.

Clinical features:

Affect is inadequate, at Odds
with thought, disharmonious--
an absence of adequate affect.
NO manic-depressive compon-
ent. Massive paranoia; in the
chronic stage, delusions are
poorly organized.

 

functioning; normal siblings;
normally protective, accepting
mother; accepting father; het-
erosexual behavior; verbal ag-
gression; much capacity for
alcohol; success despite adver-
sity; harmony between ability
and achievement; harmony be-
tween culture and environment.

Acute, abrupt, sudden, stormy
onset, with a significant and
logical precipitating stress or
situation present. Later onset.
Abrupt break and change.

Nervous; sleepless; worried;
nightmares; hypochondriasis;
somatic complaints; moody; im-
patient; tantrums; fault-finding;
moralizing.

These symptoms represent a
rather distinct change in per-
sonality and habits.

Prominent affective features,
with a possible manic-depres-
sive component. Lots of anx-
iety, depression, turmoil, dis-
turbance. Minor paranoid
trends; neither organized nor

systematic delusions. Delusions

 

70

APPENDIX I (Continued)

 

 

Process

Reactive

 

Clear sensorium--relative1y
well oriented.

Awareness of change in self.

Somatic delusions.

Loss of decency--nudity, pub-
lic masturbation.

are less prominent than the ac-
companying affective features.
Confusion--disoriented.

No sensation of change.
Absence of somatic delusions.
Retention of decency.

Other clinical and experimental features:

Loss of capacity to abstract.
Presence Of thinking disorders
on the Rorschach. Poor re-
sponse to treatment. Lengthy
stay in hospital. Anxiety pre-
cipitated only by epiniphrine,
and a marked blood pressure
response to this drug. Low
basal blood pressure; small,
unsustained drop after mecholyl
--short time of homeostasis.
Failure of blood pressure to
rise under most stresses.

Abstraction intact. Absence or
slight degree of thinking dis-
orders on the Rorschach. Good
response to treatment. Short
stay in hospital. Anxiety pre-
cipitated or relaxed only by
mecholyl. Moderate blood pres-
sure re5ponse to epiniphrine.
High basal blood pressure; large,
sustained drop of systolic blood
pressure after mecholyl--long
time of homeostasis (return of
systolic blood pressure after
injection).

 

 

APP E ND IX II

71

72

3.3853 Huh—502
, r... h ....._... .. .. . .4...

w . A a .

 

73

 

Ho stile Stimulus

74

 

Dependency Stimulus

75

m :Hsflufim Hmoxom

 

.ne: '( “ii '
Il~~...~e..l [LE 01 LY Date Due

 

 

Demco-293