INTELLIGENCE AND PSYCHOSIS
Authors: F. L. WELLS, C. M. KELLEY
Journal: American Journal of Psychiatry (1920)

according to diagnosis of 102 psychotic cases examined by the Stanford intelligence scale: par. 1-11. Retests: par. 12-13. Scattering: of tests: par. 14-20. Technical considerations and criticisms of detail: par. 25-34. Incidents: par. 35-42. Cases dominated by volitional disturbance: par. 43-51. Cases with IQ above 1.00: par. 52-74. "Intelligence" as ideational capacity, distinguished from capacities for dealing with concrete things, or adjustments to other personalities: par. 75-87. Interrelations of intelligence, psychosis, happiness and general adaptation: par. 88. 1. This study is based upon examination in 102 cases of mental disease. The observations cover a period between September, 1916, and July, 1917, and from February, 1919, to April, 1919. The number examined represents approximately the cases in McLean Hospital within these periods from whom the necessary cooperation was obtainable. The percentage of admissions thus susceptible to examination was about 60. The material is not otherwise selected, and comprises various psychoses in both men and women, in order as they came to the attention of the examiner. 2. Studies using the Yerkes adolescent scale in a similar sort of material have been reported by Pressey1,9 and by Curtis.2 Pressey compared groups of alcoholic and dementia præcox cases with feeble-minded of corresponding mental ages. Curtis employs data from various psychoses, also from the feeble-minded, but is more concerned with questions of "scattering" than with absolute mental ages. The results of both investigations coincide with the present at their points of contact. The present material does not contain alcoholic cases, nor does feeble-minded material enter save incidentally. Both Pressey and Curtis find more "scattering" ering" in the psychotic than in the feeble-minded. Pressey finds mental ages generally below normal, his groups averaging between 10 and 11 years. Curtis seems to have found the higher scores with special frequency under the diagnosis of psychopathic personality. 3. In the present material, the majority of cases were examined within a short interval after admission. There are a few chronic cases who had been in the hospital for long periods; otherwise, the examinations do not represent special relation to the course of the psychosis, except as indicated in the retests. See PDF for Table 4. Chronological ages of the present subjects range from i6 to 75 years. The IQ thus represents mental age divided by 16. In observing relationships of individual tests in the scale, frequent use is made of the mental age figure as such. As representing "age" its significance is conventional only. It is not to be presumed that psychotic individuals of a given mental age mentally resemble normal, feebleminded or other psychotic individuals of like mental age, otherwise than is implicit in the specific tests performed. 5. The above table abstracts the material according to diagnostic groups, giving data upon age, sex and IQ. 6. Reductions of IQ in this material are subject to various interpretations. Apathy and negativism in schizophrenia, thinking difficulty in manic-depressive depressions, distractibility in excitements, memory and attention failures in organic conditions, are factors able to account for reduced IQ in the respective psychoses. None of them in necessarily present in any psychosis to such a degree as to markedly reduce the IQ. There is no case in the material of the Kraepelinian paranoia in which, so far as discernible, IQ would be unaffected; but it appears unaffected in the "paranoid conditions" observed. 7. Reduction of IQ is greatest in the organic cases, and frequently not evident in the manic-depressive or schizophrenic groups. There is ample demonstration that reduction of "intelligence" to subnormal is not a necessary accompaniment of grave mental disorder. The organic are the only defined groups showing no IQ's above 1.00. In these cases alone does intelligence defect show definite association with the psychosis. Yet the highest IQ obtained in these groups (.96) was associated with judgment defect and delusions (persistent, not delirious) of unusual social gravity. 8. Among the present psychoses, little diagnostic importance attaches to the IQ. In some manic-depressive conditions, reduced IQ (associated with "scattering," cf. par. 14) may indicate superposed organic involvement not otherwise apparent, with consequent modification of the prognosis. 9. In central tendency of IQ, the non-organic groups are similarly affected. This is in accord with Pressey's1 experience, though there was greater reduction in his material. Over half the present IQ's are above the level below which independent adjustment is for reasons of intelligence no longer possible. A few are considerably above the normal level. Certain psychoses develop along lines imperfectly or not at all reached by measures of "intelligence." 10. The age standards of the vocabulary test, which correlate well with "mental age" in normal adolescents, do not preserve this relationship in the present material. As derived from par. 5, the distribution of IQ's is as follows: .20 .30 .40 .50 .60 .70 .80 .90 1.00 1.10 No. cases. 1 1 4 7 5 17 19 28 16 4 The highest year group in which the vocabularly test (not made in one case) is passed, distributes as follows: Year Group less than VIII-VIII. X. XII. XIV. XVI. XVIII. No. cases. 1 3 3 24 19 19 49 The vocabulary test appears least affected of all functions in the scale. "Superior adult" ability in vocabulary is associated with deficiency in remaining aspects of intelligence down to the upper limits of feeble-mindedness. 11. Four cases in the material have IQ's of the "superior adult" level. In repeating digits forward this level is reached by 25 cases. Though to a less degree than vocabulary, this somewhat formal ability is relatively spared by the incidence of psychosis. Repeating digits backwards approximates more closely to the general intelligence distribution, superior adult ability being reached by 13 cases, and average adult by 16. 12. Retests indicate a sphere of usefulness for the scale in quantitative demonstration of progressively lost or recovered functions. Both are illustrated in the following abstract of material on this point. 13. Clinical examination of mental cases properly involves some formal tests of the same general character as find place in the intelligence scales. These formal tests are ordinarily crude, without other standard than the examiner's little organized impressions. Over such procedure the scales offer improvement, not less because they may be entrusted to persons specially trained therefor, to the release of physicians for more specific responsibilities. Where circumstances do not justify full scale examination, certain abridgments have been found useful, while preserving the standard character. 14. A practically convenient criterion of "scatter" is the number of tests failed below and passed above the mental age of the individual. In the findings of Curtis,2 by the "variation total" of the Yerkes adolescent scale, "scatter" is greater among feeble-minded than normal, and greater among psychotics than feeble-minded. Among the psychoses, the dementia præcox group records more "scatter" than the manic-depressive, and the syphilitic psychoses (only organic group represented) more See PDF for Table "scatter" than the dementia præcox , though the difference are small. The present material is in harmony with these results, average "scatter" in different psychoses being as follows: Manic-depressive depression... 5.9 Whole manic-depressive group. 5.7 Constitutional psychopathy ... 5.6 Dementia præcox......... 6.2 General paralysis............ 7.8 Whole organic group.......... 7.6 15. A more elaborate measure of "scatter" is proposed by Pressey,' which aims to weigh the scattered tests according to their "scatter" than the dementia preæcox, though the differences are amount of displacement from the mental age. The manicdepressive depressed, dementia præecox and general paralysis groups of the present material were thus compared, with the following results: Weighted. "Scatter." (Months.) Av. m.v. Manic-depressive depressed .................. 22.7 6.7 Dementia præcox ........................ 25.4 13.7 General paralysis ........................... 31.0 12.3 15a. The greatest number of scattered tests observed in an individual was 15, yielding a weighted score of 58, in an acute drug psychosis. Three subjects showed no "scatter," one a paranoid condition of normal mental age, the second a deteriorated dementia præcox, the third, exceptionally, a deteriorated general paralytic ( Case 8, par. 12). 16. With such exceptions as are noted below, reduction of IQ does not select special test functions according to diagnostic group. Various tests, however, do not have the same difficulty for the psychotic, as for a normal person of given mental age. Data on this point have been examined for all tests made over 25 times. Comparisons are based on the percentage of times a test was made where there was a failure below the mental age of the subject, and the per cent of subjects having mental age above that of the test, who fail therein. 17. Tests failed by no one below mental age are: Comprehension, 3d degree ( VIII-3), stamps total value (IX-a2) and the vocabulary tests. Other tests very seldom failed below mental age are: Comprehension, 4th degree (X-5), makes change (IX-3), Healy-A ( Xa3), abstract words ( XII-2), dissected sentences (XII-4). Tests showing marked tendency to fail below mental age are: Weights, serial arrangement (IX-2), rhymes (IX-6), enclosed boxes (XVI-4). Outstanding positions of difficulty for the psychotic subjects belong to: Designs (X-3), reading and report (X-4) and Ball and field superior plan (XII-3). 18. The following tests above year VIII are never passed by a subject having mental age below their year-group: All nine-year tests except making change; all ten-year tests save vocabulary, comprehension, 4th degree, and 60 words. Tests passed above age with relative infrequency are: Fables score 4 (XII-5), comprehension, 4th degree (X-5), makes change (IX-3), stamps total value (IX-a2), ball and field superior plan (XII-3). frequency of passing above mental age is, as previously indicated, most marked in the vocabulary and formal memory tests. 19. Examination of "scatter" on single tests according to diagnosis is made for the manic-depressive depressed, dementia præcox and organic groups. Absurdities (X-2), designs (X-3), reading and report (X-4), which are never passed above age, are failed with similar frequency in the three groups. The superior plan of ball and field (XII-3) fails below age over twice as often in the dementia præcox group as in the manic-depressive or organic. In the repetition of five and six digits backwards (XII-6, XVI-5), the manic-depressive and organic groups togather record nine failures below age and two passes above; the dementia præcox group records one failure below age and eight passes above. In the repetition of six and seven digits forward (X-aI, XIV-aI) the manic-depressive and organic groups record 13 failures below mental age to none by the dementia præcox group. Other differential features are not indicated. 20. If all regular tests of a year group are made, alternate tests, even though made, do not figure in the IQ; but in statements of "scatter," alternate tests are included irrespective of whether or not they figure in the IQ. 21. The 1916-17 data were recorded upon the published"record booklets." Recording on the booklet is desirable while the tests are being learned, but superfluous after familiarity with the tests is acquired, a single letter-size sheet being suitable for record of data practically significant in scoring. It is necessary to have at hand a single copy of the record booklet for various references. Most of the 1919 data were recorded upon a single sheet form. 22. The record booklet classifies the tests by the ages to which they attach. The single sheet of present reference classifies them according to topics. This presentation of the tests effects some saving of time and distributes failures and successes fairly evenly through the examination. Among the disadvantages are that evaluating is less simple, and a basal year less readily fixed. It is indicated that the most desirable record, form for such a scale is one that occupies a single letter-size sheet, lists the tests thereon by year groups, uses a homogeneous system of numbering the tests, and gives the homologous tests (as of vocabulary, pictures and figures backward) the same position in the year groups where they occur. 23. The minimum range of testing sanctioned by Terman4 is all passed but one at the lower limit and all failed but one at the upper. The uniform range of the present material is from a basal year in which all tests are passed, to an upper limit in which one test only is passed. The basal year is the highest year within and below which there are no failures. The material contains ains cases of failures below years where all tests were passed. All passes above age and failures below it are thus not necessarily reached, resulting errors being left to compensate. 24. The median number of tests necessary to cover the employed loyed range of testing is 35. In a random group of 30 cases in the material of the Massachusetts School for Feeble-minded, kindly furnished by Dr. Mateer, the median number of tests made is 45. A greater range appears to have been prescribed. There is also less scope for testing in the present material, as the basal years come nearer the upper limit. The M. S. F. 30 cases contain no basal year above 8; the distribution of basal years in the present material is as follows: Basal year ...... 3—3 4 5 6 7 8 9 10 12 14 No.cases ....... 1 0 2 1 6 9 18 27 19 12 7 25. Certain experience with particular tests will be recorded. Some criticisms of detail are of factors inherent in the scale, others arise from the present application thereof to a use for which it was not constructed. The Stanford scale is primarily adapted for children, and the higher level tests for older, brighter children rather than for normal or inferior adults. 26. In their present connection, certain comprehension items are objectionable in the childishness of their phraseology and the situations they present. These advantages are somewhat offset by phrasing in the third person ("What should a man (or boy) do"), etc. The situation may also be changed to one more in harmony with adult life ("If you are to meet someone"), etc. 27. The objection of incongruity with the adult mind appearsalso in the sentence memory tests, encountered most frequently in X-a2 and XVI-a1. If the tests are of sufficient significance, standardization may be attempted or more adult types of sentence, examples (difficult) of which are quoted in the appendix (D). Similar objection exists to the item, "I asked my teacher," etc. 28. The ball and field situation is incongruous for most adults, especially women. Much more satisfactory service has been obtained through a presentation which supposes that a soldier is sent by his commanding officer to hunt for a pair of field glasses, packet of papers, or other object of military value, lost in the field. 29. The use of the silver dollar in VII-a1 is doubtfully applicable to eastern conditions. In test IX-3 it is convenient to make the object of purchase postage stamps instead of candy. Knowledge of the date (IX-i) has evident limitations in the case of persons living under hospital conditions. 29a. There is a difference between the child and adult mind which puts the adult at a disadvantage in the pictures test (111-3, etc.). A just ground for scoring interpretation higher in a scale for adolescents is that the children who gave interpretations are brighter than those who give descriptions, but there are grave difficulties in the way of maintaining that interpretation is itself the higher form of response. The adult is not so free to use his imagination as is the child, and thus produces less readily an interpretation which, however reasonable, he knows to be imaginary. The issue of interpretation may be clearly raised, while specific interpretation is declined. In these cases full credit is allowable. The direction, "Explain this picture," did not work intelligibly with the present material. The question, "What does (or might) this picture represent?" is useful in eliciting good interpretation from those able to give it. 30. Most of the absurdities (X-2) might have been paraphrased from the "Ruthless Rhymes for Heartless Homes." Their sadistic note is disturbing to some depressed patients. The same feature is present in the problems of fact (XIV-4). An observed and legitimate deduction for the "queer visitors" is that of marriage after a pregnancy not so legitimate. 31. The 6o-word test (X-6) does not lend itself well to adult reaction types. It might be advantageous to uniformity substitute the Healy-A (X-a3). 32. The item 8. 1o in the clock test (XIV-6) is objectionable since reversal places the hour hand exactly at 2.00. The item should read 8.08. (Cf. appendix, B). 33. The items for repeating seven digits (XIV-aI) each contain a digit repeated twice. The third item for repeating eight digits (XVIII-3) contains a digit repeated twice; the other two items do not. It is not clear from Terman's manual whether the commingling of these items was intentional or fortuitous. According to work of Ranschburg's5 and other related experience, repetition of digits should change the difficulty of the series. Objection has been made to number-sequences occurring in the items for repetition of digits. In the appendix (A) are quoted number series believed to avoid them. 34. In the ingenuity test (XVIII-6), it is recommended that quarts be substituted for pints in the presentation, as the more common and natural of the two units to work with. Many subjecets make the change of their own accord. The situation still suffers from incongruity for adults, with their less plastic imaginations. Trial has been made with a situation using medicines, where more precise measurement is naturally called for. The test is extremely subject to coaching; a series of alternate problems is quoted in the appendix (E). (In formulating the solutions of these problems, very considerable practice was experienced.) 35. Among depressed patients there is a tendency to give good responses with accompanying assurance that they are insufficient, and request that they be not recorded. This is part of the selfdepreciation symptomatic of the psychosis. The responses, when correct, are recorded as such. 36. The scoring of the induction test requires correctness of both the sixth response and the governing rule. Two cases occur where all responses were correct, but the governing rule was not satisfactorily produced ("I simply guess from the way things were multiplying that you keep on multiplying"); the other case produced the rule satisfactorily on leading question only. Two other cases gave the governing rule unexceptionably, but failed in the multiplication of 16 by 2. 37. To the ball and field test, a depressed patient, drawing an unsystematic response, said, "I suppose some people would have some system, but I wouldn't." The failure may be from thinking difficulty, or the self-depreciation described in par. 35. On retest after improvement, the superior plan was produced (Case 3, par. 12). 38. Another patient described a superior plan of reaction to the ball and field test, but actually drew an inferior one. This patient (IQ .95) had delusions of exceptional fixity, that he was responsible for the condition of other patients, and for various more remote terrestrial evils. This attitude of vicarious accountability irradiated into an otherwise correct interpretation of the Colonial Home picture; "and the dog is responsible for it in some way." 39. Effect of psychosis in producing specifically perverted responses is most conspicuous in the judgments of dementia præcox. A case so developing, not at the time clinically diagnosed as such, interpreted the Dutch Home, Canoe, Post Office and Colonial Home pictures respectively as follows: "A child who has been punished; cruel to the cat, maybe." "A man kidnapping a girl has hired two Indians to help him." "Reading about some murder-perhaps five men gossiping about the woman walking to her house....something disgusting....they think they're very witty." "A woman who has been kidnapped crying because she can't go back to her home." 40. The scale gives scope for perseveration to be shown, as (wood and coal) "burning"; (apple and peach) "they'll burn all right." .... "round." Other apparent instances, shown in a case of general paralysis, are: (Plumbing) "tinner's utensil "; (outward) " tinner's utensil, used in all sorts of ways." (Quake) "is generally used to crack the earth"; (civil) "is generally used to crack the earth"; (treasury) "is generally used by people who understand it." (Broken something) "return it and have it fixed"; (danger of being late) "hurry up and fix it as quick as I could." (Opinion of unknown person) "leave them alone." (Important undertaking) "let him have his own judgment." 41. In a depressed patient, self-depreciatory trends cropped out in such responses to the vocabulary test as (majesty) "Noble— I am not noble"; (conscientious) "true—I have not been true." A related attitude appears in this patient's response to (broken something): "Go and acknowledge it." It is unfortunate that the religious doctrines of repentence and absolution are so easily perverted in this direction. The ethical standard reflected occurs oftener than it should in normal life. 42. Piscatorial occasionally acquires an ecclesiastical meaning (Episcopalian) overdetermined, no doubt, by an unconscious ixθύζ. A case of drug psychosis surpassed the normal expectation in classifying book, teacher and newspaper as "all well read." "A white man riding on a horse too small for him" affords an ingenious escape from the expected interpretation of the Indian's remark. A manic disciple of Anaxagoras would respond to the vocabulary test only when formulated, "what do people mean by....?" 43. If a busy executive is asked to undergo an intelligence examination he will not always comply; no "credits" will be earned, but to infer corresponding intelligence defect is absurd. Delusional motives or instability of feeling may cause psychotic cases to similarly decline or obstruct examination, when it is clear that good records would be made otherwise. In all cases, the "intelligence" factor in the performance is underlain by that of voluntary co-operation, secured through good-will or self-interest. Volitional as well as intellectual disturbances are capable of reducing the IQ. The defects of adjustment are equally real in either case, but they have different causes, which, outside the sphere of the tests, have different effects. 44. It is well observed that dementia præcox is characterized by the failure of conduct to maintain its level with the intellect; it is a volitional disorder rather than an intellectual one. But it is only through conduct of some sort (as speaking) that intellect is manifested. The disorder attacks first the more fundamental, instinctive, "real," types of conduct, and leaves relatively untouched the more conventional "laboratory" type of reactions. Particularly does this apply to the language mechanism, through which any degree of intellect is to be manifested. Hence the high IQ in grave dementia præcox cases. Ultimately this type of behavior also may be deeply involved. The appearance is then that of dementia, of the stuporous or scattered type. What is actually observed is a conduct disorder, in which the status of the intellect is not clear. There is reason to regard it as much better preserved than in the organic dementias. 45. Case 10, the dementia præcox case of IQ .24, par. 5, lowest observed in this material, is considered in this light. Peculiarities of make-up characteristic of dementia præcox are not recorded in this case, but the course of the psychosis has been typical. He was admitted in August, 1912, and the examination dates September 9, 1916. His condition was stabilized at this time, and there has been substantially no change since. 46. Clinical notes of the time the examination was made record that the patient has been somewhat quieter than previously; is good in working voluntarily on the ward; sweeps and polishes the floor every morning. Eats and sleeps well. Walks about making gymnastic motions, whistling, singing, turning rapidly in the opposite direction; looks over the paper and smokes, talking and laughing to himself. The "mental age" in the scale is three years ten months, notable difference existing between the present picture and that of a normal person of this age. 47. General notes of the examination read: "Much blocked, especially in language responses. Co-operation of the main personality seems willing. Is deferential to examiner and assists his work in various ways." Characteristic of the examination as detailed, is that the patient shows he has the information called for, but manifests it in an abnormal way. The former criterion governs in the assignment of the present credits. Performance in the tests is shown in table on page 30. Of 26 subsequent tests recorded, all are failed except the vocabulary tests of years VIII and X. In the vocabulary test, much scattered talk would be added to the definatory words upon which the item was passed. Scattered talk was also produced to items failed, this tendency decreasing as the words grew more difficult. It consisted largely of stereotyped phrases as: "Quantity of representation of things that have use"; "material that it is"; "there is quite a difference according to the uses of it." "Use and uses that it is" "it's according to the quantity of the use and uses of the speech of it." No. Nature of test. Pass or fail. III. 1. Points to parts of body.—, total. 6. Repeats seven syllables. - Ar. Repeats three digits. - IV. 2. Discrimination of forms. + 2. Names colors. 3. Æsthetic comparison. - 4. Definitions, use or better. + 5. Patience. Ar. Age. VI. 1. Right and left. 2. Mutilated pictures. 3. Counts 13 pennies. 4. Comprehension 2d. deg. + 5. Coins. +, total 6. Repeats 16 to i8 syllables. - Cf. 111-6. 2. Names familiar objects. + 3. Picture enumeration. - 5. Gives last name. + 3. Counts four pennies. + 4. Copies square. + 5. Comprehension, 1st. deg. - 6. Repeats four digits. - AI. Repeats 12 to 13 syllables. - V. i. Comparison of weights. + Remarks. Other performance indicates this due to motor blocking. Points to objects called for. Produces nothing relevant. Shows written address, points to last name. Language blocking is against correct response. Do. Points, amid scattered talk, to each form without error; "Quite a resemblance." Covers all with four fingers and holds up this number. Well and carefully done. Only irrelevant talk. Cf. 111-6. Tips them a little with forefinger, and points with unintelligible mumbling. Red is called "dull red," showing superior discrimination. Shuts eyes, produces irrelevant talk. Chair, "convenience" (points). Horse, "creature"; fork, "implement"; table "furnishing"; doll and pencil, failure. Shows how pieces were taken apart, but will not move them. Indicates both hands. Points ("optic"). Points without naming to mouth, nose, arms. Names arms on urging. Counts properly, finally says "thir -thir- thirteen." Amid scattered talk, produces successively "umbrella," "sprinkler, telephone, telegraph, fire department"; "automobile or wait till next car comes." Among the responses upon which items were credited correct, are the following: Eyelash, particle of hair. Health, condition, muscles, body. Mellow, condition of food or drink, taste, whiskey. Lecture, classified as a sermon or any such thing, a speech. Treasury, place where they have quantity of money, bank. Reception, hostess, gentleman of the house. Skill, (goes through movements of shadow boxing). Insure, insurance policy, endowment. Repose, quiet. Shrewd, furthering of his interest. Charter, certificate, diploma. Conscientious, faithful, kind. Swaddle, some kind of clothing. Philanthropy, cheerful giver, philanthropist. Flaunt, flag to the breeze. 48. Similar features appear in a retest of the psychopathic case with IQ .36 in par. 5 ( Case 7, par. 12). In the retest, 27 months later, the IQ is .28. This case is a woman aged 29 and 32 at the respective tests, who has always been deficient, deterioratation to lower level now supervening. Along with her mental age at retest of four years six months, she is able to write a clear though childish hand, and to read as indicated in the examination. She appears to read very light stories, and to look at pictures for amusement. Her chief occupation is writing, in which she produces scattered material, with stereotypies. (Test material she wrote as: "The dogs runs afters the cats"; "Sees the littles boys"; "We are goings have a fimes in the countrys.") She is very neat about her room, spends much time in cleaning and keeping everything in order. ( At retest, seeing the examiner resting note-paper upon his knee, she spontaneously cleared a table stacked with papers, and smilingly placed it for the examiner to write on.) 49. In the examination the patient made no verbal responses, except, in a scarcely audible whisper, a wrong statement of her age. Normal responses were obtained where language was not needed, as in III-I, pointing to parts of body. Otherwise, the correct information was either written by the patient, or identified from a number of alternatives written by the examiner. Among the tests passed in this way