Journal of Youth and Adolescence, VoL 3, No. 4, 1974
Schizophrenia in Adolescence 1 Philip S. H o l z m a n 2 a n d R o y R. G r i n k e r , Sr. 3
Received May 22, 4974
The emergence o f schizophrenic psychoses during middle and late adolescence poses the question o f how adolescence as a developmental stage is related to the emergence o f severe psychopathology. This paper examines several possible explanations for adolescence as the beg#ruing o f the high-risk age, particularly for the schizophrenias. After discussing the nature o f adolescence as distinguished from puberty, and then considering the nature o f schizophrenia, we report some data from a long-range study o f young adult psychiatric patients, both schizophrenic and nonschizophrenic. Our data support the idea that serious psychopathology- not only schizophrenia- occurs in a setting o f poor competence in a variety o f crucial skills which include the social, intellectual, and physical realms. The demands made on adolescents by societal expectations for This work is supported in part by Public Health Service grants MH-05519, MH-18991, and MH-19477. t This research is part of a program investigating schizophrenia which is being conducted jointly by the Psychosomatic and Psychiatric Institute of Michael Reese Hospital, the Department of Psychiatry, Pritzker School of Medicine, University of Chicago, and the Illinois State Psychiatric Institute. 2Professor in Psychiatry and Psychology, University of Chicago, Chicago, Illinois, and Training and Supervising Psychoanalyst, Chicago Institute for Psychoanalysis, Chicago, Illinois. Received his Ph.D. in psychology from the University of Kansas. His research has been in individual consistencies in cognition and perception, and more recently in perceptual aspects of severe psychopathology. He was for 22 years on the senior staff of the Menninger Foundation, where he performed clinical and research functions, including that of Training and Supervising Analyst in the Topeka Psychoanalytic Institute, and Director of Research Training. He currently is a recipient of a Career Scientist Award from the NIMH (K5-MH-70900). 3 Director of the Institute for Psychosomatic and Psychiatric Research and Training, Michael Reese Hospital and Medical Center, University of Chicago, Chicago, Illinois, and Professor of Psychiatry, University of Chicago, Chicago, Illinois. Received his medical degree from Rush Medical College in Chicago. His psychiatric and psychoanalytic training took place in Chicago, Vienna, Zurich, Hamburg, and London. His research has been in psychosomatic medicine, stress and anxiety, clinical syndromes (including schizophrenia), normal development, and psychotherapy. 267 9 P l e n u m Publishing C o r p o r a t i o n , 2 2 7 West 1 7 t h Street, N e w Y o r k , N . Y . I0011. N o part o f this p u b l i c a t i o n m a y be r e p r o d u c e d , stored in a retrieval system, or t r a n s m i t t e d , in any f o r m or by any means, e l e c t r o n i c , mechanical, p h o t o c o p y i n g , m i c r o f i l m i n g , r e c o r d i n g , or o t h e r w i s e , w i t h o u t w r i t t e n p e r m i s s i o n o f t h e publisher.
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independence and role establishment summon a variety o f competencies. Where these competencies are dysfunctional, societal demands strain an already rubberable youth, and potentiate disorganization.
INTRODUCTION Most investigators agree that the high-risk age for the onset of schizophrenic psychoses begins at 17 years. Although schizophrenic psychoses occur among younger children, it is the adult form which is the most prevalent. Moreover, it is striking that the age at visible onset varies little across national boundaries. Middle and late adolescence seem to coincide with a marked increase in the incidence o f schizophrenic psychoses, at least as measured by the number of first admissions per year to mental hospitals (Mayer-Gross et al., 1969, p. 239). We are making here a clear distinction between schizophrenia on the one hand and ~chizophrenic psychosis or overt schizophrenia on the other. The former describes a long-standing pattern of withdrawal, general apathy, poor object-relationships, peculiar and even disorganized thinking with occasional impulsive, perhaps antisocial acts but without hallucinations or delusions. The latter denotes a clear-cut severance o f reality constraints with many secondary features of psychosis such as delusions and hallucinations in a setting that is otherwise schizophrenic and neither o f organic etiology nor o f cyclic-affective etiology. Statistical data from both the United States and the United Kingdom, as Table I shows, indicate that at the younger ages many more males than females enter hospitals with schizophrenic psychoses, and it is only after age 35 that the ratio shifts. The age-specific rate rises from about 1 per 100,000 under 15 years to about 25 per 100,000 in the age 15-24. Table II, which shows the cross-national
Table I. Admission Rate for Schizophrenia in England and Wales in 1960
Age group
Annual admission rate per million M F
10to 11 13 15 to 247 224 20 to 458 283 25 to 403 350 35 to 254 275 45 to 119 195 55 to 70 139 65 to 30 84 75 plus 23 68 From Mayer-Grossetal. (1969, p. 239).
Sex ratio M/F 0.87 1.18 1.46 1.15 0.95 0.58 0.48 0.42 0.38
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Table II. Relative Rates of First Admissions for Schizophrenia to Mental Hospitals by Age: United States (1964), England and Wales (1960), Czechoslovakia (1963), Denmark (1961), Victoria, Australia (1962) Age 15 15-24 25-34 3544 45-54 55-64 65 plus
United States 8 148 217 171 103 55 12
England and Wales Czechoslovakia 3 171 216 152 91 61 34
7 156 189 180 102 60 28
Denmark
Victoria, Australia
2 137 208 137 112 104 67
3 108 187 193 126 67 73
From Yolles and Kramer (1969).
relative rates o f first admissions, dramatically underscores the constancy of the picture across countries. What factors can account for the clear emergence of overt schizophrenic illness during adolescence? Are adolescence and schizophrenia unrelated to each other, and is their coincidence therefore simply attributable to chance factors? Is schizophrenia a disorder which, like Huntington's chorea, occurs at a particular age because o f the time necessary for its inexorable "incubation"? Is adolescence a pathogenic a g e n t - a n intrinsic f a c t o r - w h i c h potentiates or triggers schizophrenia? Or do the social demands of adolescence - extrinsic factors -- precipitate schizophrenia in a person who is vulnerable to that disorder? That is, will such a vulnerable person manifest symptoms because social task-demands have begun to intrude significantly on the growing adolescent? This paper examines these possibilities and draws on data from an ongoing study of young adult schizophrenic patients to attempt a resolution of these questions, after first considering the nature o f adolescence and of schizophrenia. We believe that our data support the hypothesis that adolescence imposes severe demands for social, interpersonal, and intrapersonal competence on the biologically and psychologically vulnerable adolescent. These demands seriously challenge him and thus precipitate a retreat from the development of competence into psychopathology.
THE NATURE OF ADOLESCENCE Although there is a tendency in common usage helpful to distinguish puberty from adolescence. Puberty ing maturational phase o f development which consists results in the appearance and development o f secondary
to elide the two, it is is a biologically unfoldin hormonal shifts and sex characteristics. The
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age at onset varies from one geographic region to another, but generally in girls puberty begins at about 10-1 2 years, with the onset o f breast growth and pubic hair, and the beginning of menstruation: in boys puberty begins at about 11-14 years, with the enlargement of the penis and testicles, growth of pubic hair, and the occurrence of ejaculation. These changes bring with them psychological adaptations consisting principally in an awareness of sexual and sensual feelings within one's own body, an awareness of one's changed physical appearance, an awkwardness felt in the new bodily changes, feelings of shame, guilt, and concern over measuring up to cultural ideals o f appearance and behavior. Adolescence, on the other hand, may be viewed as a culturally defined stage of the life cycle in which there is a transition in roles from childhood to adulthood. The age at onset, as with puberty, varies from culture to culture, but in tile case of adolescence it is begun by cultural rather than biological events. Tile principal characteristic of adolescence is a shift from childhood dependence to adult independence, from demanding of others to being demanded of, from being provided for to providing for. This transition involves a movement from the nuclear family to a new and different primary group. Ties with one's own family must be severed as tile fledgling adult begins to develop skills in working and in loving. Attention turns from caring for oneself to caring for one's mate, one's offspring, and one's social and cultural milieu. The onset of adolescence is more or less indicated by tile already developed biological markers of puberty. The end of adolescence, wlfich merges into young adulthood, is even more highly individual and indefinite. It has no specific age, no biological marker, and may continue far into what chronologically we call adulthood. Cultures differ in tile demands they place on young adults and they also differ in the degree to which they ease the young into adult roles. Thus the behavioral manifestations o f adolescence vary from one culture to another. That which seems to be constant, however, is the fact of resistance to or ambivalence over changing roles, a resistance that may be experienced more or less consciously, depending on tile sanctions o f the society and o f the times. In Western culture of the twentieth century, adolescents express their ambivalence over assuming new adult roles by such behavior as rebelliousness, sullen negativism, zealous compliance, asceticism, overintellectuality, and regressive passivity. Society, in its demands for a new generation to assume early responsibilities, has disrupted the adaptations o f childhood and placed strains on those aspects of psychological organization which must now be mobilized. Most adolescents manage to endure the bodily changes o f puberty. They grow psychologically into their new bodies; mental maturity gradually becomes congruent with sexual maturity; acne clears; and awkwardness gives way to a modicum of grace. But the social and psychological demands o f adolescence place a different quality o f strain on the young person. These behavioral demands occur several years after the onset of puberty, generally in the first year after high school. It is then, particularly in the middle classes o f Western culture,
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that the young person begins to separate himself from his nuclear family, leaves l~ome, either for work or for higher education, begins to form his own family, and incurs the myriad expectations that society requires one to fulfill. This phase of development is not without its psychological consequences, and few young people leave it without experiencing forms of loneliness, anxiety or fear, challenge, elation, or thrust. Responses of clinical anxiety, despair, and depression are not infrequent. As Erikson (1974) formulated it, "In youth you find out what you care to d o and who you care to b e - - e v e n in changing roles. In young adulthood you learn whom you care to be w i t h - - at work and in private life, not only exchanging intimacies, but sharing intimacy. In adulthood, however, you learn to know what and whom you can t a k e care oJ~" Psychoanalytic observers have typically regarded adolescence as intrinsically a time of turmoil and imbalance, a developmental period which occasions the revival of yet earlier conflicts that reproduce oedipal struggles and oral and anal concerns. It is the revival of these conflicts in sufficient strength, many psychoanalysts believe, that leads to their resolution by disengagement from the nuclear family. At this time, the adolescent struggles against accepting the support his family offers while feeling that he needs that support. His increased fantasying activity includes an exaggeration of his own capacities. This grandiosity can be a source of both comfort and disillusionment when reality probes the unrealistic aspects of the fantasy. The adolescent finds additional comfort and solace in temporary identifications of himself with figures outside the home, some of which are congruent with his own and his family's previous ideals and some of which are polar opposites. Psychoanalytic investigators, moreover, have shown that the psychological nature of these struggles tends to become concretized. Fantasies of engagement and disengagement with people, for example, are regarded as real, to be acquired, exploded, or hoarded. Feelings for others can be pierced, or they may be engulfed, poisoned, or paralyzed by their feelings. Althot, gh these are metaphoric ways of speaking about internal mental states, they feel real and actual to the adolescent who must contend with such issues. But psychoanalytic insights have been based on studies of adolescents who have been experiencing intense conflict and whose pain has motivated them to seek professional help. Some others have sought help because of the prolongation of their adolescent struggles and because they need more time and additional help to see them through the passage to adult responsibilities. Is the intensity of the struggles of these young people representative of that of the entire population of adolescents? Although the in-depth scrutiny made possible by the unique psychoanalytic interview is not available for general population surveys, several studies of normal adolescents -- that is, of those who have not sought clinical help--emphasize the continuity between childhood and adulthood. They suggest that the disruptive and disjunctive patterns of disturbed
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adolescents may not be at all typical, and that the pathological degrees of anxiety, negativism, rebelliousness, isolation, and asceticism may not be inevitable in adolescence but rather predictable from the quality of earlier patterns of coping with adversity, stress, and challenge. And the family, regarded by many adolescents-in-turmoil and by some of their healers as noxious, may actually provide a supportive relationship to the adolescent, and thus represent a positive factor. The studies of normal development to which we refer are the Berkeley (Block, 1971), Cambridge (Vaillant, 1971), Haverford (Heath, 1965), and Chicago (Grinker et al., 1962) studies. In the Berkeley study, Block evaluated longitudinal data on 171 subjects. The data included school grades, teachers' reports, interviews, ratings of social behavior, and many psychological test scores. The results show that a number of subjects remained relatively stable while others changed a good deal between their high school years and adulthood. Yet even in the most extreme changers, continuity is evident. Male "nonchangers" seemed to be self-confident, quick, resourceful, and vigorous, in contrast to the male "changers," who seemed to be dependent, unsure of themselves, tense, and guarded. For the females, however, the "changers" seemed to be the ones who were assertive, competent, and eager to chart their own independent destinies. The incidence of psychopathology in this group of 171 was extraordinarily small. At Haverford, Heath studied a number of "mature" and "immature" students and did longitudinal assessments of them for several years. Although most students showed periods of disorganization and instability when first confronted with the novelty of college life, most settled into a stable and autonomous life course. Thus although the majority of the young people in Heath's sample experienced regressive periods of disorganization, most of them emerged without permanent psychopathological handicaps. Vaillant studied 240 persons by interview and questionnaire methods at 2-year intervals over a period of 30 years. The subjects were chosen in 1940 while they were college sophomores and were presumed to be psychologically and physically healthy, to be more intelligent, more verbal, and in better physical health, and to have better motivation for achievement than the average college student. The principal focus was on the continuity of defensive behavior. Vaillant's periodic interviews may be compared with time-lapse photography in that they present in a short interval the major shifts in style of defense which took place over 30 years. The conceptual scheme in which Vaillant's group viewed defenses takes the form of a hierarchy. The first level, containing psychotic denial, distortion, and delusion, he labeled narcissistic. These defenses are discernible in healthy persons prior to the age of 5, and in adults they continue to appear in primaryprocess formations such as dreams and fantasies. They function to alter an unbearable reality. The second level, called immature defenses and containing projection, schizoid fantasying, hypochondriasis, acting out, and passive-aggres-
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273
sive behavior, appears in healthy persons from the age of 13 to late adolescence. They function to change distressing affects that attend threats of object loss. The third level, called neurotic defenses, contains intellectualization and related mechanisms of repression, displacement, reaction formation, and dissociation or neurotic denial. These seem characteristic of healthy people from the age of 3 on through life. They function to alter "private feelings or instinctual expression." The highest level is labeled mature deJbnses, which are common in healthy persons from puberty on through life. These defenses -- such as altruism, humor, suppression, sublimation, and anticipation--are based on mature cognitive functions and include high-level identifications with appropriate objects. The long follow-up period made it possible to discern continuity and structure in behavior. Thus far, data on 30 subjects suggest that whether a person employs immature or mature defenses separates the subjects into poor and good life adjustment groups, although all subjects showed liberal use of neurotic defenses. Continuity could be discerned in the reliance on mature and immature defenses. Severe psychopathology did not contravene in a setting of mature adaptation. The intervention of severe life stresses, however, could force a reliance on progressively less adaptive defensive patterns from which recovery was probable with an abatement of the stress. In the Chicago project, Grinker studied 80 male students (and later a second group of 54) of a small Midwestern college. He determined that these young men of average intelligence and Iower middle class origins reported little adolescent turbulence, although there was some increase in conflict with their parents during adolescence. He called this group of subjects homoclites in order to characterize their general conformity. Only six of the 80 showed some mildly deviant characteristics in the form of tendencies to act out and mild bitterness of outlook or shyness. In general, however, these men experienced their adolescent transitions as smooth. They displayed good physical health from childhood on. Birth and pregnancy complications were minimal or absent. They reported positive, affectionate, and warm relationships with both parents, and experienced continual communication with them. Sociability and general contentment in a setting of striking conventionality were typical. A follow-up of these subjects 15 years later showed that none of these subjects had experienced psychological disorganization serious enough to warrant hospitalization or a visit to a mental health worker (Grinker and Werble, 1974). The rather good adjustment, absence of psychopathology, and freedom from serious social and work failures that characterized the "homoclites" in 1958 remain typical of them 16 years later. These qualities of normal adolescents were also described by Offer and Offer (1973), who studied 84 high school students over several years. Fewer than 15% of the group dropped out of college, but half of these returned to school after working for 1 year. The Offers described three "routes" through adolescence: (1) Continuous growth. Those in this group--about 23% of the total population -- seemed to be the steadiest, most adaptable of the subjects.
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(2) Surgent growth. These subjects showed some significant incidence of crises, with a slight tendency to react with mild depression. Yet these subjects never lost sight of their long-range goals. About 35% of the total group showed this quality of growth. (3) Tumultuous growth. The adolescents in this group were those who reacted to external trauma as if it were "a major tragic event." Separation from the family was an important issue, and self-confidence was not well established in these young people. About 21% of the total group were so classified. The Offers' conclusions emphasized that turmoil and pathology do not define the adolescent period, although periods of disruptive behavior do occur. These studies suggest that adolescence is not an intrinsically pathogenic period. Although some tunnoil is discernible, there is no indication of major disruptions in young persons whose earlier behavior was not deviant. All of these studies of normal adolescence emphasized that there are many styles of adaptation in adolescence and only a small number of these predict later psychopathology. The emphasis, however, is on the fact that the tasks of adolescence demand social and interpersonal, motor, and intellectual competence. They do not demand high degrees of skill in any particular area, but they do require a nidus of competence in most of these areas, for genuine emancipation from one's nuclear family is built on revision, modulation, flexible acceptance of adversity, and a mastery of opportunities. Just as adolescence does not produce pathology, it does not produce competence. But given a previously competent child, the tasks of adolescence will be mastered well, even though temporary regressions will be encountered.
SOME ASPECTS OF THE SCHIZOPHRENIAS
Since 1970 we have been studying young adults who have suffered a psychotic episode which has been diagnosed as schizophrenic. In an earlier report (Grinker and Holzman, 1973), we detailed one aspect of our studies, and focused on the clinical examination, via a semistructured interview. From the tape recordings of these interviews, our research team rated a number of aspects of the patient's functioning. Five features of these young adult schizophrenic patients emerged with some prominence. The first was their striking difficulty in maintaining what we called "organizational coherence," that is, an inability to keep percepts and ideas from disorder and disarrangement, from fluidity and disorganization. Even in periods of remission this quality of organizational instability was noteworthy. The second was the patient's prominent pleasureless demeanor, a quality of affect referred to by Rado as anhedonia. The third feature was an excessive dependency of these patients on their families, staff of hospital, and their therapists. The fourth feature was the absence of clear-cut
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evidence of general competence: these patients achieved tess in school, in their jobs, and in their social life than one would have expected on the basis of their inteUectual levels. A fifth feature was that the precipitating circumstances surrounding the need for hospitalization involved a blow to their self-esteem, thus highlighting their exquisitely vulnerable sense of self-regard. Of particular significance for our present inquiry into the relationship between adolescence and schizophrenia is the appearance of evidence of poor competence in our group of young schizophrenic patients. The strain experienced by the physically maturing schizophrenic person underscores issues of competence in already vulnerable people. Whether the vulnerability specifically implicates schizophrenia or represents a general vulnerability to psychopathology was not answered by our initial inquiry. It thus becomes important to compare the premorbid histories of schizopl3renic and nonscllizophrenic psychiatric patients and of nonpatient "normals" for the presence of evidence of poor competence in their premorbid adjustment. In this sample from our data, we looked at 49 schizophrenic patients, 18 nonschizophrenic patients (manic-depressive and personality disorders), and 37 normals. In our study, age, socioeconomic status, and intelligence level have been matched, thus eliminating the possibility of a confounding of these variables with the evidence of premorbid histories involving school, occupation, and social difficulties. Table Ill shows the distribution of these subjects. The comparison shows dramatically that the two patient groups did not differ from each other in any of the principal variables tapping competence: social and work adjustment prior to hospitalization, runaway history, school performance, dropping out of school, experimenting with street drugs, and an inner experience of themselves as lonely individuals. The normal subjects, on the other hand, showed no incidence of running away from home, poor social and work adjustment, troublesome school records, or substantial drug taking. With respect to general competence, young adult schizophrenics do not differ from other young adults who have had behavioral and interpersonal difficulties severe enough to warrant hospitalization. Both groups, however, are significantly different from the nonpathological group. Thus lack of competence in adolescence is related to later psychopathology, whatever its form. This does not imply that all disturbances of adolescence which differ from the disturbances in the nonpathological group constitute aspects of a "schizophrenic spectrum" (Kety et al., 1968). The later behaviors, difficulties, and varieties of disorganizations indicate that the nonspecific matrix of pathology in adolescence includes all those who are destined to become severely disturbed, including those who become overtly schizophrenic. Other investigators such as Bromet et al. (1974) contend that certain specific premorbid factors can predict a future "process" schizophrenia. We believe, on the basis of our data, that these premorbid disturbances are quite nonspecific with respect to the future form of psychopathology.
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Holzman and Grinker Table III. Percentage of Subjects in Each Group of Young Adult Patients (Ages 17-24) Who Manifested Evidence of Poor Competence and Premorbid Ineffectiveness Schizophrenic patients (N = 49)
Nonschizophrenic patients (N = 18)
Rate of onset Unknown Sudden Gradual
2 20 78
6 33 61
Adjustment prior to onset Unknown Good Fair Poor
9 10 51 38
33 50 16
59 12 10
50 11 5
14 4
11 22
Runaway history Unknown Present Absent
2 69 29
0 77 22
School performance Unknown Excellent Good Fair Poor
4 10 18 28 39
11 27 11 11 39
School dropout Unknown No Yes
2 31 67
5 33 61
Drug taking No Yes
39 61
44 56
Lonely Unknown No Yes
2 31 67
44 5 50
Prominent dependency Unknown No Yes
0 24 76
0 33 67
Little affection Unknown No Yes
4 24 71
0 44 56
Antecedent stress Unknown External stress Developmental stress External and developmental stress Other
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Our findings, however, are not unique. Other investigators have reported similar patterns. For example, Rodnick and Goldstein (1972) studied interactions in families of adolescents at risk for serious psychopathology. They reported a range of intrafamilial conflicts, significant frequency of withdrawal behavior, excessive dependency on parents, isolated social behavior, and antisocial behavior. Holmes and Barthell (1968) reported that school performance of later schizophrenic patients showed poor academic and social achievement. Watt et aL (1970)report similar data, with boys and girls showing deficits in competency in specific areas. Watt (1972) further noted that about 50% of the schizophrenic patients showed deviant social behavior by early adolescence, a statistic that is in substantial agreement with ours. Robins' (1966) study of the precursors of psychopathology reported that the children who later became schizophrenic differed in significant ways from those who remained free of major psychopathology. Those who became schizophrenic had more infectious illness in early childhood, more physical handicaps, a greater number of eating and sleeping disturbances, and antisocial behavior. Antisocial behavior was a particularly striking finding, with 50% of those children having had an incident of physical aggression and incorrigibility. Nameche and Ricks (1966) reported a slower motor development and inferior coordination among schizophrenics as children than in any comparison group. Delayed development of speech, unclear speech, and social isolation were striking. These data are congruent with those reported by Bender and Freedman (1952) and Fish and Hagin (1972). Are these patterns of maladaptation and inferior competence to be regarded as precursors or early manifestations of later serious psychopathological symptoms, that is, prodromal symptoms of the disorder? Are they the preconditions for the development of major psychopathology? Are they artifacts of the method of retrospective recall, a method notoriously subject to contextual distortion (Haggard et al., 1960; Hilles, 1967)? It would seem that the followback methods used by Watt and Robins established that these data are not artifacts of the recall by distraught parents; these investigators organized data which had been recorded many years before major mental illness had been diagnosed. Garmezy (1974) has suggested that perhaps these indications of behavior difficulties in childhood are themselves the manifestation of the disorder which later establishes itself. This is a reasonable view and one that implies that the schizophrenic psychosis is merely a phase in an evolving pathological process, a phase which is marked by serious disorganization and loss of allegiance to reality. It appears to us that the schizophrenias refer to a dys-organization of adaptive and defensive functions which in turn reflects more fundamental dysfunctions of basic physiological and psychological processes. By "fundamental" we mean early in time -- perhaps prenatally -- and we mean genotypic. The particular derailments in development are too heterogeneous to reflect
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specific pathologies of specific organ structures. The persistent and ubiquitous disturbances in a variety of areas of functioning are sufficiently nonspecific to suggest that the pathology is to be characterized in terms of degrees of failure of developnaental differentiation. Such failures may be more or less observable, depending on the psychological, social, or physical tasks required of the person. In early childhood, strains on psychological resources are for the most part considerably less than they will be in later life. School and parental demands for conformity or for achievement may represent serious strains to some particularly vulnerable children. These children are probably those who show behavior deviations noted in the Robins (1966) study and others. But adolescence, with its insistent denrands for separation and individuation, for taking a role in society, and for performing it with competence, imposes inescapable burdens on a vulnerable organism. In the vulnerable person, response is weak, inappropriate, inadequate, avoidant, defiant, absent, apathetic, ineffective, desperate, eccentric, or compliant-at-great-cost. From this perspective, it is understandable that the statistics regarding first hospitalizations for schizophrenic patients show that young males outnumber young females until the fourth decade of life, when females are in the majority. For the task demands on young adult males are vastly greater than those on young females. Requirements for competence in the soc!al, occupational, and sexual realms are considerably greater for males than for females. The young male must, in most cultures, establish himself in an occupation and become sexually aggressive enough to court and marry a woman, and to maintain sexual, social, and occupational potency. Thus in men limitations in competence will become apparent early and task demands will impose heavy challenges. For young women in our culture, on the other hand, the requirements for independence and initiative are less than they are for young men. Thus the appearance of overt disorganization - the psychotic phase of the disorder -- is less apparent in young women. During the fourth decade of life, however, when child-rearing activities are less insistent, families will more readily extrude a schizophrenic female as now expendable. Hence the higher hospitalization rates for women than for men after age 35. In our view, then, the relationship between adolescence and schizophrenia is that of a catalyst to a biological reaction. The potential for disorganization is characteristic of the person. The social tasks of adolescence, however, place powerful strains on a vulnerable youth, and such a person must draw on his limited resources to respond to these task requirements. His responses thus expose his deficits, and the strain of the requirement to become competent can potentiate disorganization. The consequences of such failures to the adolescent's sense of worth, self-esteem, and pride are great; they add finite burdens to his failures already sensed throughout the preceding years.
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REFERENCES Bender, L., and Freedman, A. M. (1952). A study of the first three years of maturation of schizophrcnic children. Quart. J. Child Behav. 1 : 245-272. Block, J. (1971). Lives Through Time, Bancroft, Berkeley, Calif. Bromet, E., Harrow, M., and Kasl, S. (1974). Premorbid functioning and outcome in schizophrenics and non-schizophrenics. Arch. Gen. P&vchiat. 30: 203-207. Erikson, E. H. (1974). Dimensions o f a New Identity, Norton, New York. Fish, B., and Hagin, R. (1972). Visual-motor disorders in infants at risk for schizophrenia. Arch. Gen. Psychiat. 27: 594-598. Grinker, R. R., Sr., and Holzman, P. S. (1973). Schizophrenic pathology in young adults: A clinical study. Arch. Gen. Ps),chiat. 28:168-175. Grinker, R. R., Sr., and Werble, B. (1974). Mentally healthy young men (homoclites) 14 years later. Arch. Gen. Psychiat. 30: 701-709. Grinker, R, R., Sr., Grinker, R. R., Jr., and Timberlake, I. (1962). "Mentally healthy" young males (llomoclites). Arch. Gen. Psychiat. 6: 405-453. Haggard, E. A., Brekstad, D., and Skaxd, A, G. (1960). On the reliability of the anamnestic interview, J. Abnorm. Soc: Psyehol. 61:311-318. Heath, D. (1965). Explorations hi Maturity, Appleton-Century-Crofts, New York. Hilles, L. (1967). The reliability of anamncstic data. Bull. Menn#Tger Clin. 31:219-228. Hohnes, D., and Barthell, C. (1968). High school yearbooks: A nonreactive measure of social isolation in graduates who later become schizophrenic. J. Abnorm. Psychol. 73: 313-316. Kety, S. S., Rosenthal, D., Wendcr, P. H., and Schulsinger, F. (1968). Thc types and prevalence of mental illness in the biological and adoptive families of adopted schizophrenics. In Rosenthal, D., and Kety, S. S. (eds.), The Transmission o f Schizophrenia, Pergamon Press, Oxford. Mayer-Gross, W., Slater, E., and Roth, M. (1969). ClinicalPsychiatrv. 3rd ed., Williams and Wilkins, Baltimore. Nameche. G. H., and Ricks, D. F. (1966). Life patterns of children who becanle adult schizophrenics. Presented at the Annual Meeting of the American Orthopsychiatry Association, San l:rancisco, April 16. Offer, D., and Offer, J. (1973). Normal adolescence in perspective. In Schoolar, J. C. (ed.), Current Issues in Adolescent Psychiatry. Brunner/Mazel, New York. Robins, N. (1966). Deviant Children Grown Up. Williams and Wilkins, Baltimore. Rodnick, E. H., and Goldstein, M. J. (1972). A research strategy lbr studying risks for schizophrenia during adolescence and early childhood. Paper presented at Conference on Risk Research, Dorado Beach, Puerto Rico, October. VaiUant, G. E. (1971). Theoretical hierarchy of adaptive ego mechanisms. Arch. Gen. Psyehiat. 24: 107. Watt, N. F. (1972). Longitudinal changes in the social behavior of children hospitalized for schizophrenia as adults. J, Nerv. Ment. Dis. 155:42-54. Watt, N. F., Stolorowrd Lubcnsky, A. W., and McCleUand, D. C. (1970). Social adjustment and behavior'of children hospitalized for schizophrenia as adults. Am. J. Orthopsychiat. 40: 637-657. Yolles, S. F., and Kramer, M. (1969). Vital Statistics in the Schizophrenic Syndrome (L. Bellak, ed.), Grune and Stratton, New York.
Schizophrenia in Adolescence 1 Philip S. H o l z m a n 2 a n d R o y R. G r i n k e r , Sr. 3
Received May 22, 4974
The emergence o f schizophrenic psychoses during middle and late adolescence poses the question o f how adolescence as a developmental stage is related to the emergence o f severe psychopathology. This paper examines several possible explanations for adolescence as the beg#ruing o f the high-risk age, particularly for the schizophrenias. After discussing the nature o f adolescence as distinguished from puberty, and then considering the nature o f schizophrenia, we report some data from a long-range study o f young adult psychiatric patients, both schizophrenic and nonschizophrenic. Our data support the idea that serious psychopathology- not only schizophrenia- occurs in a setting o f poor competence in a variety o f crucial skills which include the social, intellectual, and physical realms. The demands made on adolescents by societal expectations for This work is supported in part by Public Health Service grants MH-05519, MH-18991, and MH-19477. t This research is part of a program investigating schizophrenia which is being conducted jointly by the Psychosomatic and Psychiatric Institute of Michael Reese Hospital, the Department of Psychiatry, Pritzker School of Medicine, University of Chicago, and the Illinois State Psychiatric Institute. 2Professor in Psychiatry and Psychology, University of Chicago, Chicago, Illinois, and Training and Supervising Psychoanalyst, Chicago Institute for Psychoanalysis, Chicago, Illinois. Received his Ph.D. in psychology from the University of Kansas. His research has been in individual consistencies in cognition and perception, and more recently in perceptual aspects of severe psychopathology. He was for 22 years on the senior staff of the Menninger Foundation, where he performed clinical and research functions, including that of Training and Supervising Analyst in the Topeka Psychoanalytic Institute, and Director of Research Training. He currently is a recipient of a Career Scientist Award from the NIMH (K5-MH-70900). 3 Director of the Institute for Psychosomatic and Psychiatric Research and Training, Michael Reese Hospital and Medical Center, University of Chicago, Chicago, Illinois, and Professor of Psychiatry, University of Chicago, Chicago, Illinois. Received his medical degree from Rush Medical College in Chicago. His psychiatric and psychoanalytic training took place in Chicago, Vienna, Zurich, Hamburg, and London. His research has been in psychosomatic medicine, stress and anxiety, clinical syndromes (including schizophrenia), normal development, and psychotherapy. 267 9 P l e n u m Publishing C o r p o r a t i o n , 2 2 7 West 1 7 t h Street, N e w Y o r k , N . Y . I0011. N o part o f this p u b l i c a t i o n m a y be r e p r o d u c e d , stored in a retrieval system, or t r a n s m i t t e d , in any f o r m or by any means, e l e c t r o n i c , mechanical, p h o t o c o p y i n g , m i c r o f i l m i n g , r e c o r d i n g , or o t h e r w i s e , w i t h o u t w r i t t e n p e r m i s s i o n o f t h e publisher.
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independence and role establishment summon a variety o f competencies. Where these competencies are dysfunctional, societal demands strain an already rubberable youth, and potentiate disorganization.
INTRODUCTION Most investigators agree that the high-risk age for the onset of schizophrenic psychoses begins at 17 years. Although schizophrenic psychoses occur among younger children, it is the adult form which is the most prevalent. Moreover, it is striking that the age at visible onset varies little across national boundaries. Middle and late adolescence seem to coincide with a marked increase in the incidence o f schizophrenic psychoses, at least as measured by the number of first admissions per year to mental hospitals (Mayer-Gross et al., 1969, p. 239). We are making here a clear distinction between schizophrenia on the one hand and ~chizophrenic psychosis or overt schizophrenia on the other. The former describes a long-standing pattern of withdrawal, general apathy, poor object-relationships, peculiar and even disorganized thinking with occasional impulsive, perhaps antisocial acts but without hallucinations or delusions. The latter denotes a clear-cut severance o f reality constraints with many secondary features of psychosis such as delusions and hallucinations in a setting that is otherwise schizophrenic and neither o f organic etiology nor o f cyclic-affective etiology. Statistical data from both the United States and the United Kingdom, as Table I shows, indicate that at the younger ages many more males than females enter hospitals with schizophrenic psychoses, and it is only after age 35 that the ratio shifts. The age-specific rate rises from about 1 per 100,000 under 15 years to about 25 per 100,000 in the age 15-24. Table II, which shows the cross-national
Table I. Admission Rate for Schizophrenia in England and Wales in 1960
Age group
Annual admission rate per million M F
10to 11 13 15 to 247 224 20 to 458 283 25 to 403 350 35 to 254 275 45 to 119 195 55 to 70 139 65 to 30 84 75 plus 23 68 From Mayer-Grossetal. (1969, p. 239).
Sex ratio M/F 0.87 1.18 1.46 1.15 0.95 0.58 0.48 0.42 0.38
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Table II. Relative Rates of First Admissions for Schizophrenia to Mental Hospitals by Age: United States (1964), England and Wales (1960), Czechoslovakia (1963), Denmark (1961), Victoria, Australia (1962) Age 15 15-24 25-34 3544 45-54 55-64 65 plus
United States 8 148 217 171 103 55 12
England and Wales Czechoslovakia 3 171 216 152 91 61 34
7 156 189 180 102 60 28
Denmark
Victoria, Australia
2 137 208 137 112 104 67
3 108 187 193 126 67 73
From Yolles and Kramer (1969).
relative rates o f first admissions, dramatically underscores the constancy of the picture across countries. What factors can account for the clear emergence of overt schizophrenic illness during adolescence? Are adolescence and schizophrenia unrelated to each other, and is their coincidence therefore simply attributable to chance factors? Is schizophrenia a disorder which, like Huntington's chorea, occurs at a particular age because o f the time necessary for its inexorable "incubation"? Is adolescence a pathogenic a g e n t - a n intrinsic f a c t o r - w h i c h potentiates or triggers schizophrenia? Or do the social demands of adolescence - extrinsic factors -- precipitate schizophrenia in a person who is vulnerable to that disorder? That is, will such a vulnerable person manifest symptoms because social task-demands have begun to intrude significantly on the growing adolescent? This paper examines these possibilities and draws on data from an ongoing study of young adult schizophrenic patients to attempt a resolution of these questions, after first considering the nature o f adolescence and of schizophrenia. We believe that our data support the hypothesis that adolescence imposes severe demands for social, interpersonal, and intrapersonal competence on the biologically and psychologically vulnerable adolescent. These demands seriously challenge him and thus precipitate a retreat from the development of competence into psychopathology.
THE NATURE OF ADOLESCENCE Although there is a tendency in common usage helpful to distinguish puberty from adolescence. Puberty ing maturational phase o f development which consists results in the appearance and development o f secondary
to elide the two, it is is a biologically unfoldin hormonal shifts and sex characteristics. The
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age at onset varies from one geographic region to another, but generally in girls puberty begins at about 10-1 2 years, with the onset o f breast growth and pubic hair, and the beginning of menstruation: in boys puberty begins at about 11-14 years, with the enlargement of the penis and testicles, growth of pubic hair, and the occurrence of ejaculation. These changes bring with them psychological adaptations consisting principally in an awareness of sexual and sensual feelings within one's own body, an awareness of one's changed physical appearance, an awkwardness felt in the new bodily changes, feelings of shame, guilt, and concern over measuring up to cultural ideals o f appearance and behavior. Adolescence, on the other hand, may be viewed as a culturally defined stage of the life cycle in which there is a transition in roles from childhood to adulthood. The age at onset, as with puberty, varies from culture to culture, but in tile case of adolescence it is begun by cultural rather than biological events. Tile principal characteristic of adolescence is a shift from childhood dependence to adult independence, from demanding of others to being demanded of, from being provided for to providing for. This transition involves a movement from the nuclear family to a new and different primary group. Ties with one's own family must be severed as tile fledgling adult begins to develop skills in working and in loving. Attention turns from caring for oneself to caring for one's mate, one's offspring, and one's social and cultural milieu. The onset of adolescence is more or less indicated by tile already developed biological markers of puberty. The end of adolescence, wlfich merges into young adulthood, is even more highly individual and indefinite. It has no specific age, no biological marker, and may continue far into what chronologically we call adulthood. Cultures differ in tile demands they place on young adults and they also differ in the degree to which they ease the young into adult roles. Thus the behavioral manifestations o f adolescence vary from one culture to another. That which seems to be constant, however, is the fact of resistance to or ambivalence over changing roles, a resistance that may be experienced more or less consciously, depending on tile sanctions o f the society and o f the times. In Western culture of the twentieth century, adolescents express their ambivalence over assuming new adult roles by such behavior as rebelliousness, sullen negativism, zealous compliance, asceticism, overintellectuality, and regressive passivity. Society, in its demands for a new generation to assume early responsibilities, has disrupted the adaptations o f childhood and placed strains on those aspects of psychological organization which must now be mobilized. Most adolescents manage to endure the bodily changes o f puberty. They grow psychologically into their new bodies; mental maturity gradually becomes congruent with sexual maturity; acne clears; and awkwardness gives way to a modicum of grace. But the social and psychological demands o f adolescence place a different quality o f strain on the young person. These behavioral demands occur several years after the onset of puberty, generally in the first year after high school. It is then, particularly in the middle classes o f Western culture,
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that the young person begins to separate himself from his nuclear family, leaves l~ome, either for work or for higher education, begins to form his own family, and incurs the myriad expectations that society requires one to fulfill. This phase of development is not without its psychological consequences, and few young people leave it without experiencing forms of loneliness, anxiety or fear, challenge, elation, or thrust. Responses of clinical anxiety, despair, and depression are not infrequent. As Erikson (1974) formulated it, "In youth you find out what you care to d o and who you care to b e - - e v e n in changing roles. In young adulthood you learn whom you care to be w i t h - - at work and in private life, not only exchanging intimacies, but sharing intimacy. In adulthood, however, you learn to know what and whom you can t a k e care oJ~" Psychoanalytic observers have typically regarded adolescence as intrinsically a time of turmoil and imbalance, a developmental period which occasions the revival of yet earlier conflicts that reproduce oedipal struggles and oral and anal concerns. It is the revival of these conflicts in sufficient strength, many psychoanalysts believe, that leads to their resolution by disengagement from the nuclear family. At this time, the adolescent struggles against accepting the support his family offers while feeling that he needs that support. His increased fantasying activity includes an exaggeration of his own capacities. This grandiosity can be a source of both comfort and disillusionment when reality probes the unrealistic aspects of the fantasy. The adolescent finds additional comfort and solace in temporary identifications of himself with figures outside the home, some of which are congruent with his own and his family's previous ideals and some of which are polar opposites. Psychoanalytic investigators, moreover, have shown that the psychological nature of these struggles tends to become concretized. Fantasies of engagement and disengagement with people, for example, are regarded as real, to be acquired, exploded, or hoarded. Feelings for others can be pierced, or they may be engulfed, poisoned, or paralyzed by their feelings. Althot, gh these are metaphoric ways of speaking about internal mental states, they feel real and actual to the adolescent who must contend with such issues. But psychoanalytic insights have been based on studies of adolescents who have been experiencing intense conflict and whose pain has motivated them to seek professional help. Some others have sought help because of the prolongation of their adolescent struggles and because they need more time and additional help to see them through the passage to adult responsibilities. Is the intensity of the struggles of these young people representative of that of the entire population of adolescents? Although the in-depth scrutiny made possible by the unique psychoanalytic interview is not available for general population surveys, several studies of normal adolescents -- that is, of those who have not sought clinical help--emphasize the continuity between childhood and adulthood. They suggest that the disruptive and disjunctive patterns of disturbed
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adolescents may not be at all typical, and that the pathological degrees of anxiety, negativism, rebelliousness, isolation, and asceticism may not be inevitable in adolescence but rather predictable from the quality of earlier patterns of coping with adversity, stress, and challenge. And the family, regarded by many adolescents-in-turmoil and by some of their healers as noxious, may actually provide a supportive relationship to the adolescent, and thus represent a positive factor. The studies of normal development to which we refer are the Berkeley (Block, 1971), Cambridge (Vaillant, 1971), Haverford (Heath, 1965), and Chicago (Grinker et al., 1962) studies. In the Berkeley study, Block evaluated longitudinal data on 171 subjects. The data included school grades, teachers' reports, interviews, ratings of social behavior, and many psychological test scores. The results show that a number of subjects remained relatively stable while others changed a good deal between their high school years and adulthood. Yet even in the most extreme changers, continuity is evident. Male "nonchangers" seemed to be self-confident, quick, resourceful, and vigorous, in contrast to the male "changers," who seemed to be dependent, unsure of themselves, tense, and guarded. For the females, however, the "changers" seemed to be the ones who were assertive, competent, and eager to chart their own independent destinies. The incidence of psychopathology in this group of 171 was extraordinarily small. At Haverford, Heath studied a number of "mature" and "immature" students and did longitudinal assessments of them for several years. Although most students showed periods of disorganization and instability when first confronted with the novelty of college life, most settled into a stable and autonomous life course. Thus although the majority of the young people in Heath's sample experienced regressive periods of disorganization, most of them emerged without permanent psychopathological handicaps. Vaillant studied 240 persons by interview and questionnaire methods at 2-year intervals over a period of 30 years. The subjects were chosen in 1940 while they were college sophomores and were presumed to be psychologically and physically healthy, to be more intelligent, more verbal, and in better physical health, and to have better motivation for achievement than the average college student. The principal focus was on the continuity of defensive behavior. Vaillant's periodic interviews may be compared with time-lapse photography in that they present in a short interval the major shifts in style of defense which took place over 30 years. The conceptual scheme in which Vaillant's group viewed defenses takes the form of a hierarchy. The first level, containing psychotic denial, distortion, and delusion, he labeled narcissistic. These defenses are discernible in healthy persons prior to the age of 5, and in adults they continue to appear in primaryprocess formations such as dreams and fantasies. They function to alter an unbearable reality. The second level, called immature defenses and containing projection, schizoid fantasying, hypochondriasis, acting out, and passive-aggres-
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sive behavior, appears in healthy persons from the age of 13 to late adolescence. They function to change distressing affects that attend threats of object loss. The third level, called neurotic defenses, contains intellectualization and related mechanisms of repression, displacement, reaction formation, and dissociation or neurotic denial. These seem characteristic of healthy people from the age of 3 on through life. They function to alter "private feelings or instinctual expression." The highest level is labeled mature deJbnses, which are common in healthy persons from puberty on through life. These defenses -- such as altruism, humor, suppression, sublimation, and anticipation--are based on mature cognitive functions and include high-level identifications with appropriate objects. The long follow-up period made it possible to discern continuity and structure in behavior. Thus far, data on 30 subjects suggest that whether a person employs immature or mature defenses separates the subjects into poor and good life adjustment groups, although all subjects showed liberal use of neurotic defenses. Continuity could be discerned in the reliance on mature and immature defenses. Severe psychopathology did not contravene in a setting of mature adaptation. The intervention of severe life stresses, however, could force a reliance on progressively less adaptive defensive patterns from which recovery was probable with an abatement of the stress. In the Chicago project, Grinker studied 80 male students (and later a second group of 54) of a small Midwestern college. He determined that these young men of average intelligence and Iower middle class origins reported little adolescent turbulence, although there was some increase in conflict with their parents during adolescence. He called this group of subjects homoclites in order to characterize their general conformity. Only six of the 80 showed some mildly deviant characteristics in the form of tendencies to act out and mild bitterness of outlook or shyness. In general, however, these men experienced their adolescent transitions as smooth. They displayed good physical health from childhood on. Birth and pregnancy complications were minimal or absent. They reported positive, affectionate, and warm relationships with both parents, and experienced continual communication with them. Sociability and general contentment in a setting of striking conventionality were typical. A follow-up of these subjects 15 years later showed that none of these subjects had experienced psychological disorganization serious enough to warrant hospitalization or a visit to a mental health worker (Grinker and Werble, 1974). The rather good adjustment, absence of psychopathology, and freedom from serious social and work failures that characterized the "homoclites" in 1958 remain typical of them 16 years later. These qualities of normal adolescents were also described by Offer and Offer (1973), who studied 84 high school students over several years. Fewer than 15% of the group dropped out of college, but half of these returned to school after working for 1 year. The Offers described three "routes" through adolescence: (1) Continuous growth. Those in this group--about 23% of the total population -- seemed to be the steadiest, most adaptable of the subjects.
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(2) Surgent growth. These subjects showed some significant incidence of crises, with a slight tendency to react with mild depression. Yet these subjects never lost sight of their long-range goals. About 35% of the total group showed this quality of growth. (3) Tumultuous growth. The adolescents in this group were those who reacted to external trauma as if it were "a major tragic event." Separation from the family was an important issue, and self-confidence was not well established in these young people. About 21% of the total group were so classified. The Offers' conclusions emphasized that turmoil and pathology do not define the adolescent period, although periods of disruptive behavior do occur. These studies suggest that adolescence is not an intrinsically pathogenic period. Although some tunnoil is discernible, there is no indication of major disruptions in young persons whose earlier behavior was not deviant. All of these studies of normal adolescence emphasized that there are many styles of adaptation in adolescence and only a small number of these predict later psychopathology. The emphasis, however, is on the fact that the tasks of adolescence demand social and interpersonal, motor, and intellectual competence. They do not demand high degrees of skill in any particular area, but they do require a nidus of competence in most of these areas, for genuine emancipation from one's nuclear family is built on revision, modulation, flexible acceptance of adversity, and a mastery of opportunities. Just as adolescence does not produce pathology, it does not produce competence. But given a previously competent child, the tasks of adolescence will be mastered well, even though temporary regressions will be encountered.
SOME ASPECTS OF THE SCHIZOPHRENIAS
Since 1970 we have been studying young adults who have suffered a psychotic episode which has been diagnosed as schizophrenic. In an earlier report (Grinker and Holzman, 1973), we detailed one aspect of our studies, and focused on the clinical examination, via a semistructured interview. From the tape recordings of these interviews, our research team rated a number of aspects of the patient's functioning. Five features of these young adult schizophrenic patients emerged with some prominence. The first was their striking difficulty in maintaining what we called "organizational coherence," that is, an inability to keep percepts and ideas from disorder and disarrangement, from fluidity and disorganization. Even in periods of remission this quality of organizational instability was noteworthy. The second was the patient's prominent pleasureless demeanor, a quality of affect referred to by Rado as anhedonia. The third feature was an excessive dependency of these patients on their families, staff of hospital, and their therapists. The fourth feature was the absence of clear-cut
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evidence of general competence: these patients achieved tess in school, in their jobs, and in their social life than one would have expected on the basis of their inteUectual levels. A fifth feature was that the precipitating circumstances surrounding the need for hospitalization involved a blow to their self-esteem, thus highlighting their exquisitely vulnerable sense of self-regard. Of particular significance for our present inquiry into the relationship between adolescence and schizophrenia is the appearance of evidence of poor competence in our group of young schizophrenic patients. The strain experienced by the physically maturing schizophrenic person underscores issues of competence in already vulnerable people. Whether the vulnerability specifically implicates schizophrenia or represents a general vulnerability to psychopathology was not answered by our initial inquiry. It thus becomes important to compare the premorbid histories of schizopl3renic and nonscllizophrenic psychiatric patients and of nonpatient "normals" for the presence of evidence of poor competence in their premorbid adjustment. In this sample from our data, we looked at 49 schizophrenic patients, 18 nonschizophrenic patients (manic-depressive and personality disorders), and 37 normals. In our study, age, socioeconomic status, and intelligence level have been matched, thus eliminating the possibility of a confounding of these variables with the evidence of premorbid histories involving school, occupation, and social difficulties. Table Ill shows the distribution of these subjects. The comparison shows dramatically that the two patient groups did not differ from each other in any of the principal variables tapping competence: social and work adjustment prior to hospitalization, runaway history, school performance, dropping out of school, experimenting with street drugs, and an inner experience of themselves as lonely individuals. The normal subjects, on the other hand, showed no incidence of running away from home, poor social and work adjustment, troublesome school records, or substantial drug taking. With respect to general competence, young adult schizophrenics do not differ from other young adults who have had behavioral and interpersonal difficulties severe enough to warrant hospitalization. Both groups, however, are significantly different from the nonpathological group. Thus lack of competence in adolescence is related to later psychopathology, whatever its form. This does not imply that all disturbances of adolescence which differ from the disturbances in the nonpathological group constitute aspects of a "schizophrenic spectrum" (Kety et al., 1968). The later behaviors, difficulties, and varieties of disorganizations indicate that the nonspecific matrix of pathology in adolescence includes all those who are destined to become severely disturbed, including those who become overtly schizophrenic. Other investigators such as Bromet et al. (1974) contend that certain specific premorbid factors can predict a future "process" schizophrenia. We believe, on the basis of our data, that these premorbid disturbances are quite nonspecific with respect to the future form of psychopathology.
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Holzman and Grinker Table III. Percentage of Subjects in Each Group of Young Adult Patients (Ages 17-24) Who Manifested Evidence of Poor Competence and Premorbid Ineffectiveness Schizophrenic patients (N = 49)
Nonschizophrenic patients (N = 18)
Rate of onset Unknown Sudden Gradual
2 20 78
6 33 61
Adjustment prior to onset Unknown Good Fair Poor
9 10 51 38
33 50 16
59 12 10
50 11 5
14 4
11 22
Runaway history Unknown Present Absent
2 69 29
0 77 22
School performance Unknown Excellent Good Fair Poor
4 10 18 28 39
11 27 11 11 39
School dropout Unknown No Yes
2 31 67
5 33 61
Drug taking No Yes
39 61
44 56
Lonely Unknown No Yes
2 31 67
44 5 50
Prominent dependency Unknown No Yes
0 24 76
0 33 67
Little affection Unknown No Yes
4 24 71
0 44 56
Antecedent stress Unknown External stress Developmental stress External and developmental stress Other
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Our findings, however, are not unique. Other investigators have reported similar patterns. For example, Rodnick and Goldstein (1972) studied interactions in families of adolescents at risk for serious psychopathology. They reported a range of intrafamilial conflicts, significant frequency of withdrawal behavior, excessive dependency on parents, isolated social behavior, and antisocial behavior. Holmes and Barthell (1968) reported that school performance of later schizophrenic patients showed poor academic and social achievement. Watt et aL (1970)report similar data, with boys and girls showing deficits in competency in specific areas. Watt (1972) further noted that about 50% of the schizophrenic patients showed deviant social behavior by early adolescence, a statistic that is in substantial agreement with ours. Robins' (1966) study of the precursors of psychopathology reported that the children who later became schizophrenic differed in significant ways from those who remained free of major psychopathology. Those who became schizophrenic had more infectious illness in early childhood, more physical handicaps, a greater number of eating and sleeping disturbances, and antisocial behavior. Antisocial behavior was a particularly striking finding, with 50% of those children having had an incident of physical aggression and incorrigibility. Nameche and Ricks (1966) reported a slower motor development and inferior coordination among schizophrenics as children than in any comparison group. Delayed development of speech, unclear speech, and social isolation were striking. These data are congruent with those reported by Bender and Freedman (1952) and Fish and Hagin (1972). Are these patterns of maladaptation and inferior competence to be regarded as precursors or early manifestations of later serious psychopathological symptoms, that is, prodromal symptoms of the disorder? Are they the preconditions for the development of major psychopathology? Are they artifacts of the method of retrospective recall, a method notoriously subject to contextual distortion (Haggard et al., 1960; Hilles, 1967)? It would seem that the followback methods used by Watt and Robins established that these data are not artifacts of the recall by distraught parents; these investigators organized data which had been recorded many years before major mental illness had been diagnosed. Garmezy (1974) has suggested that perhaps these indications of behavior difficulties in childhood are themselves the manifestation of the disorder which later establishes itself. This is a reasonable view and one that implies that the schizophrenic psychosis is merely a phase in an evolving pathological process, a phase which is marked by serious disorganization and loss of allegiance to reality. It appears to us that the schizophrenias refer to a dys-organization of adaptive and defensive functions which in turn reflects more fundamental dysfunctions of basic physiological and psychological processes. By "fundamental" we mean early in time -- perhaps prenatally -- and we mean genotypic. The particular derailments in development are too heterogeneous to reflect
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specific pathologies of specific organ structures. The persistent and ubiquitous disturbances in a variety of areas of functioning are sufficiently nonspecific to suggest that the pathology is to be characterized in terms of degrees of failure of developnaental differentiation. Such failures may be more or less observable, depending on the psychological, social, or physical tasks required of the person. In early childhood, strains on psychological resources are for the most part considerably less than they will be in later life. School and parental demands for conformity or for achievement may represent serious strains to some particularly vulnerable children. These children are probably those who show behavior deviations noted in the Robins (1966) study and others. But adolescence, with its insistent denrands for separation and individuation, for taking a role in society, and for performing it with competence, imposes inescapable burdens on a vulnerable organism. In the vulnerable person, response is weak, inappropriate, inadequate, avoidant, defiant, absent, apathetic, ineffective, desperate, eccentric, or compliant-at-great-cost. From this perspective, it is understandable that the statistics regarding first hospitalizations for schizophrenic patients show that young males outnumber young females until the fourth decade of life, when females are in the majority. For the task demands on young adult males are vastly greater than those on young females. Requirements for competence in the soc!al, occupational, and sexual realms are considerably greater for males than for females. The young male must, in most cultures, establish himself in an occupation and become sexually aggressive enough to court and marry a woman, and to maintain sexual, social, and occupational potency. Thus in men limitations in competence will become apparent early and task demands will impose heavy challenges. For young women in our culture, on the other hand, the requirements for independence and initiative are less than they are for young men. Thus the appearance of overt disorganization - the psychotic phase of the disorder -- is less apparent in young women. During the fourth decade of life, however, when child-rearing activities are less insistent, families will more readily extrude a schizophrenic female as now expendable. Hence the higher hospitalization rates for women than for men after age 35. In our view, then, the relationship between adolescence and schizophrenia is that of a catalyst to a biological reaction. The potential for disorganization is characteristic of the person. The social tasks of adolescence, however, place powerful strains on a vulnerable youth, and such a person must draw on his limited resources to respond to these task requirements. His responses thus expose his deficits, and the strain of the requirement to become competent can potentiate disorganization. The consequences of such failures to the adolescent's sense of worth, self-esteem, and pride are great; they add finite burdens to his failures already sensed throughout the preceding years.
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REFERENCES Bender, L., and Freedman, A. M. (1952). A study of the first three years of maturation of schizophrcnic children. Quart. J. Child Behav. 1 : 245-272. Block, J. (1971). Lives Through Time, Bancroft, Berkeley, Calif. Bromet, E., Harrow, M., and Kasl, S. (1974). Premorbid functioning and outcome in schizophrenics and non-schizophrenics. Arch. Gen. P&vchiat. 30: 203-207. Erikson, E. H. (1974). Dimensions o f a New Identity, Norton, New York. Fish, B., and Hagin, R. (1972). Visual-motor disorders in infants at risk for schizophrenia. Arch. Gen. Psychiat. 27: 594-598. Grinker, R. R., Sr., and Holzman, P. S. (1973). Schizophrenic pathology in young adults: A clinical study. Arch. Gen. Ps),chiat. 28:168-175. Grinker, R. R., Sr., and Werble, B. (1974). Mentally healthy young men (homoclites) 14 years later. Arch. Gen. Psychiat. 30: 701-709. Grinker, R, R., Sr., Grinker, R. R., Jr., and Timberlake, I. (1962). "Mentally healthy" young males (llomoclites). Arch. Gen. Psychiat. 6: 405-453. Haggard, E. A., Brekstad, D., and Skaxd, A, G. (1960). On the reliability of the anamnestic interview, J. Abnorm. Soc: Psyehol. 61:311-318. Heath, D. (1965). Explorations hi Maturity, Appleton-Century-Crofts, New York. Hilles, L. (1967). The reliability of anamncstic data. Bull. Menn#Tger Clin. 31:219-228. Hohnes, D., and Barthell, C. (1968). High school yearbooks: A nonreactive measure of social isolation in graduates who later become schizophrenic. J. Abnorm. Psychol. 73: 313-316. Kety, S. S., Rosenthal, D., Wendcr, P. H., and Schulsinger, F. (1968). Thc types and prevalence of mental illness in the biological and adoptive families of adopted schizophrenics. In Rosenthal, D., and Kety, S. S. (eds.), The Transmission o f Schizophrenia, Pergamon Press, Oxford. Mayer-Gross, W., Slater, E., and Roth, M. (1969). ClinicalPsychiatrv. 3rd ed., Williams and Wilkins, Baltimore. Nameche. G. H., and Ricks, D. F. (1966). Life patterns of children who becanle adult schizophrenics. Presented at the Annual Meeting of the American Orthopsychiatry Association, San l:rancisco, April 16. Offer, D., and Offer, J. (1973). Normal adolescence in perspective. In Schoolar, J. C. (ed.), Current Issues in Adolescent Psychiatry. Brunner/Mazel, New York. Robins, N. (1966). Deviant Children Grown Up. Williams and Wilkins, Baltimore. Rodnick, E. H., and Goldstein, M. J. (1972). A research strategy lbr studying risks for schizophrenia during adolescence and early childhood. Paper presented at Conference on Risk Research, Dorado Beach, Puerto Rico, October. VaiUant, G. E. (1971). Theoretical hierarchy of adaptive ego mechanisms. Arch. Gen. Psyehiat. 24: 107. Watt, N. F. (1972). Longitudinal changes in the social behavior of children hospitalized for schizophrenia as adults. J, Nerv. Ment. Dis. 155:42-54. Watt, N. F., Stolorowrd Lubcnsky, A. W., and McCleUand, D. C. (1970). Social adjustment and behavior'of children hospitalized for schizophrenia as adults. Am. J. Orthopsychiat. 40: 637-657. Yolles, S. F., and Kramer, M. (1969). Vital Statistics in the Schizophrenic Syndrome (L. Bellak, ed.), Grune and Stratton, New York.
