Archiv fr die Geschichte der Soziologie in sterreich, Graz

Mental Disorders in the Urban Environment (1939/43) By Ernest Manheim (Kansas City, Mo.)

Bearbeitete Transliteration und Kommentar von Reinhard Mller1 Faris and Dunhams recent study on the distribution of insanity rates in Chicago2 is likely to stimulate a controversy on the methodology of research in the field of let us call it socio-psychiatry. In such a discussion the basic methodological question will be the value of hospital data, such as we have, for a sociological interpretation of mental disorders. More concretely: what can the ecological picture of mental disorders such as we derive from hospital records, contribute to our knowledge about the socio-genesis of mental disorders? F[aris] & D[unham]s Chicago study contains two sets of conclusions, namely, a series of ecological relationships and an interpretation of the origin of some of the more frequent disorders. In their ecological study they have demonstrated that the incidence of schizophrenia in particular is related to other types of social disorganization, that its distribution has an axial pattern with the highest rates close to the center of the city where social mobility and density are highest and with rates diminishing toward the urban periphery where social stability is highest and where other aspects of disorganization are not apparent. Manic depressive disorders on the other hand do not seem to be correlated to mobility or any other ecological gradient except that they tend to occur on a somewhat higher economic level than schizophrenia. With reference to these two groups of disorders the authors of the Chicago study tentatively conclude that schizophrenia is an outcome of prolonged and progressive social isolation and of a progressive detachment from reality, while the absence of significant correlation in the case of manic depressive disorders indicates a stronger organic and hereditary basis. While both hypotheses are highly suggestive, the link between these two sets of conclusions, namely, between the ecological findings and their interpretation should be strengthened for reasons I shall indicate later. The ecological findings of the Chicago study seem to be borne out by parallel studies elsewhere. My study in Kansas City of which I am giving only a brief preliminary report is not yet completed. The study has been started against heavy odds census tracts had to be laid out, unpublished demographic data had to be secured, a number of parallel projects concerning housing and various aspects of social pathology had to be set up, and, in addition to all that, the hospital data had to be secured from five (5) hospitals, some of which are hundreds of miles away from Kansas City. The study is now far enough advanced to give you a visual impression of the preliminary results. For the ecological part of the study records from private and public hospitals had been secured for the period of 1925 to 1938, For other purposes records from 1920 on have been used, that is about 2900 cases altogether, All psychoses have been included in the study although cases in sufficient numbers to justify their ecological use are available only for five diagnostic groups; for senile psychoses, psychoses with cerebral arteriosclerosis, general paralysis, manic depressive psychoses and schizophrenia. For samples of about 20 to 40 percent of the total I have some data concerning the family background and education of the patient. The Kansas City picture is parallel to that in Chicago. There are some differences differences in the distribution of the old age psychoses, of the manic depressive and general paralysis cases, to some extent, but the parallel is all the more conspicuous
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Archiv fr die Geschichte der Soziologie in sterreich, Graz

as Kansas City is a different type of community. It has a large middle class population and a comparatively small working class sector, it is much more homogeneous than Chicago, it has a considerable rural background, and it is chiefly a commercial center for a large region. Schizophrenia correlates with low rents, with mobility and transience, and to some extent with a high sex ratio; it correlates with population density in so far as density coincides with mobility or with low rents, that is, with hotels, rooming houses and apartment houses. Racial heterogeneity seems to be an important factor. General paralysis correlates with transience, and foreign nativity, particularly with Russian and Italian nativity. The corresponding rates are particularly high in Negro areas. Manic depressive diagnosis are distributed in a more irregular fashion and that disorder occurs with high and low rates both in the most disorganized areas and in the more stable one-family home areas, although neighborhoods with high class homes are comparatively less affected. Now the question is, what do these findings show and what further information is needed to arrive at interpretive conclusions? I start first with some critical observations that are more commonly made by psychiatrists. There is first the problem of diagnostic variations and errors. Patients are often automatically classified as manic depressive if they have reached a certain age and have not had an attack in the past, while in the case of young patients the diagnosis is more likely to be dementia praecox. Some psychiatrists think that the greater part of the paranoid senile and simple senile cases are actually cases of late schizophrenia and they tend to restrict the senile diagnosis only to delirious patients. As a matter of fact, I have quite a number of schizophrenic diagnoses on record for patients first admitted at an age well over 60. Some psychiatrists think that a large number of cases diagnosed as paresis should be classified as schizophrenia with syphilis. Finally, there is an increasing number of complex and overlapping diagnoses such as, for example: agitated depressive superimposed on a schizophrenic background with syphilis; or paranoid schizophrenia with manic depressive features and cerebral arteriosclerosis and it is not the worst physicians who make such diagnoses. These difficulties are not decisive and with a liberal allowance for diagnostic errors and deviations the problem of classification can be temporarily eliminated, although the basic question remains: what kind of classification is of interest to the sociologist? One that is based on behavior symptoms, as in the case of manic depressive syndromes or a classification that is based on therapy, that is, on the treatment that is most successful in the particular case, as for example with psycho-neuroses; or is the sociologist interested in genetic classifications that are based on an assumed cause such as toxic psychoses or paresis? There are psychiatrists who think that many schizophrenic psychoses develop in an autotoxic process and others think that many cases of paresis and of toxic psychoses are associated with manifestations that are typical of schizophrenia. In other words, if the sociologist is interested in genetic diagnosis he will have to look for another classification than that which will satisfy him if he is interested in the manifest behavior symptoms which would most visibly distinguish the disturbed person from the pre-psychotic one. But the real problem is raised with the question which the authors of the Chicago study had anticipated but which, to my mind, calls for still further inquiry namely, the question of selective mobility. To what extent is the concentration of schizophrenic cases in certain areas due to movements of such persons into those areas and to what extent do those areas contribute to the development and not only to the outbreak of these disorders? It seems to be agreed that manic depressive psychoses
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Archiv fr die Geschichte der Soziologie in sterreich, Graz

usually occur at a later age and that the patients mostly have had time to achieve some status The onset of the attack is so sudden that the patient is likely to be sent to a hospital straight from his residence and usually from a more orthodox neighborhood. Schizophrenic persons, on the other hand, deteriorate gradually, sometimes imperceptibly. Such persons are often able to earn and to take care of themselves long after they have lost their full vitality. Moreover, schizophrenic persons, before they give reason to hospitalization, are indifferent toward their environment, they are more easily fatigued and discouraged and they are economically less successful than the future manic depressive patient. For these very same reasons the schizophrenic needs and seeks, for his mental and physical hygiene, an atmosphere of laissez-faire, of tolerance and anonymity a place where he is left alone, where he neednt explain himself and is not forced to rationalize his actions. This contrast of the seclusive schizophrenic and the socially more active manic depressive is sometimes quite striking even in hospitals. In one hospital where weekly concerts and dances are arranged for the benefit of the patients I was struck by the conspicuous non-participation of most of the schizophrenic patients while the rest of the crowd, chiefly the alcoholic, paretic, some manic depressive and even senile patients were socially quite active. It seems to me that these facts do account for high schizophrenic rates in the mobile and transient areas of the city. However, it would be worth while to trace the residence of schizophrenic patients back to their birth in as many cases as information can be made available. To put the argument in more general terms: the basic frame of reference underlying the ecological study of insanity is the community and the social role of the psychotic person in the community rather than the role of the community in the development of mental disorders. The psychiatrist who is primarily interested in the prediction and treatment of psychoses in individual instances feels that he is being told where and through what experiences are mental disorders of certain types likely to be precipitated rather than where the psychotic condition itself develops and what the mental health expectancy of a given person under given circumstances is. I feel that the Chicago study represents one of the few challenges to the psychiatrist that come from sociological research. It is for the same reason that the reaction of competent psychiatrists should be taken as a clue and as a counter challenge for further research. I see a useful clue to further studies in the following reaction that several psychiatrists have expressed. The development of many psychoses is comparatively detached from the wider social field of which the patient is only implicitly a part and that the pathological condition or the pre-disposition is present in the patient long before the precipitating experience furnishes the decisive shock. In other words, psychotic pre-dispositions develop in a social field that is not directly related to social milieu in which the disorder is finally precipitated. Some psychiatrists go as far as to say that the relationship between the two is so remote that the distribution of the diagnosis for hospitalized patients is not a representative sample of the nonhospitalized psychotic or pre-psychotic population, so that inferences from the social characteristics of the hospital population back to the causative circumstances of psychoses are not sustainable. Some even think that the social situation of most adult patients or future patients presents no more difficulties and conflicts than the average person would encounter and that the apparent problems of the patient are more typically the results than the originators of his trouble. How much psychiatric agreement is behind such statements I am unable to say, but I am giving you the most negative examples of psychiatric reaction views which I personally do not share
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Archiv fr die Geschichte der Soziologie in sterreich, Graz

fully. However, I do feel that the psychiatric emphasis on the pre-psychotic phase is one that should guide future inquiries in the field. There are two possible ways of studying the distribution and immediate situation of pre-psychotic persons. Some psychiatrists maintain that all so-called functional disorders are associated with certain metabolic deficiencies. I hesitate to use the word organic changes, because the juxtaposition of functional and organic is not always useful and it often conceals the real problem. At any rate a series of tests indicates that a number of psychoses, including schizophrenic and manic depressive ones, used to go hand in hand with a changing blood sugar curve, that is with the reduced capacity of assimilating glucose. Other tests suggest deficiencies in the red blood cells or in the function of the thyroids, to name some of the more recently advanced hypotheses. The question is not whether such deficiencies are the causes or the effects of the pathological condition the chances are that they are both. But it seems that the sociologist should be vitally interested in the development of such tests, although he can contribute nothing to it. I dont know of any significant advances in the direction of a generally applicable physical test to establish the degree of psychotic predisposition in normal persons, but if such tests should be devised in the future, we may expect to obtain most vital data about the sociological locus of mental troubles. In the meantime, we may try, with the cooperation of the sociologically interested psychiatrist, to collect data about the early history of the patient and his family. Case studies might yield significant information about the pre-psychotic person, although that is hardly expectable without direct contacts with the patient and his family and without some competency in psychiatry. It will be more important to study a few cases as intensively as possible than to cover a large number of cases extensively. While I was making a few case studies in Missouri Hospitals case studies not of the intensive sort which I suggest I was impressed by the fact that in the few cases of paranoid schizophrenia I was interested in, the family of the patient seemed to lack integration. By lack of integration I dont mean discord or lack of mutual attachment, but such divergence in the personality of the parents that tend to create conflicting identifications in the patients, while in a few cases of hebephrenic diagnosis the family recurrently lacked integration not within, but with the surrounding community. I tried to check this impression with what limited information about the background of the parents I could extract from hospital records. I used a very crude index of domestic integration. I compared first the nativity of both parents and then I related the nativity of the patient to that of his parents, coinciding nativity being an index of heterogeneity. The number of cases is too small to sustain any generalization and so I present the data for what they are worth. If my case studies were not as casual as they were and if I had a large enough sample. these data would suggest a hypotheses which is probably not very far removed from F[aris] & D[unham]s interpretation of schizophrenia. In the absence of strong enough factual evidence I dont intend to elaborate this hypotheses which is implicit in my samples. I have presented these data chiefly because they have reference to what I consider the most important phase in future research on mental disorders namely, extensive and intensive use of information about the pre-psychotic person and his background.

Archiv fr die Geschichte der Soziologie in sterreich, Graz

Summary Scope. The study covers over 2800 hospital records of first commitments to three state hospitals (Fulton, Nevada, St. Joseph) and to two private hospitals (Grandview and Robinson). This represents a coverage of approximately 95% of all psychotic patients of Kansas City, Mo. For the ecological part of the study the period 19251938 has been covered, for the statistical part the study covers the period of 19201938. The hospital records have been checked against the complete list of hospital commitments in the files of the Jackson County Court, Independence, Mo. The comparison shows that about 10% of the records of patients committed to one of the three state hospitals could not be located in the files of the corresponding state hospitals. 1. Spatial Distribution. On the whole, the distribution of rates in Kansas City is parallel to that in Chicago. However, the city fringe, including the non-industrial neighborhoods with high home ownership rates, shows increasing rates for almost all diagnoses, particularly for Paranoid Schizophrenia and for Paresis. Manic Depressive rates show a greater scatter than any other of the Schizophrenic group and Paresis, but, with some exceptions, the highest rates occur in the low rent areas and in the mobile districts. The lodging house and hotel areas, however, contribute less to the incidence of Manic Depressive rates than to the rates of the schizophrenic groups, particularly Paranoid Schizophrenia. 2. Median Age of Patients. (At first commitment) The median age of male patients is lower than that of female patients for all diagnoses. The age difference between male and female patients is greatest in the Hebephrenic and Paranoid Schizophrenic group. 3. Education. Since the number of cases for which data on education are available are limited the figures given for the groups: Catatonic Schiz[ophrenia] and Simple Schiz[ophrenia] must be regarded as not sufficiently reliable, while the size of the sample makes the value of the figures entirely problematic in the Unclassified Schizophrenia. The following ranking orders show the educational position of patients by diagnosis. + Rank order A is derived by the formula HE C , where H = the percentage of high school educated patients in the corresponding diagnostic group; C = College, and E = Elementary school educated patients (% in the respective diagnostic group). This rank order shows the proportion of high school and college educated patients by diagnosis regressing from True Paranoia to Simple Schizophrenia. Rank order B is derived by the formula E CH the same way as rankorder A. This array shows the propor+ tion of college educated patients in each group in diminishing order.

Archiv fr die Geschichte der Soziologie in sterreich, Graz

Rank Order A 1. True Paranoid 2. Catatonic Schizophrenia & Involutional Melancholia 3. Hebephrenic & Paranoid Schizophrenia 4. All Schizophrenics 5. Manic Depression 6. Unclassified Schizophrenia 7. Cerebral Arteriosclerosis 8. Senile Psychosis 9. Paresis 10.Simple Schizophrenia

Rank Order B 1. True Paranoid 2. Paranoid Schizophrenia 3. Involutional Melancholia 4. Unclassified Schizo phrenia 5. Catatonic Schizophre nia 6. Senile Psychosis 7. Manic Depressive Psychosis 8. Cerebral Arteriosclerosis 9. Hebephrenic Schizophrenia 10. Unclassified Schizophrenia 11. Paresis 12. Simple Schizophrenia

Disregarding the problematic sample of Paranoid, Involut[ional] Melancholia, and Unclassif[ied] Schizophrenia cases (though they rank fairly consistently in both series), the data show a consistently higher educational level for Catatonic Schizophrenia, Paranoid Schizophrenia, and all Schizophrenics as compared with Manic Depressives; both arrays show a consistently lower educational level for Cerebral Arteriosclerosis, Paresis, and Simple Schizophrenia. The low ranking of Cerebral Arteriosclerotic patients in series A and B may be partly due to the higher age of the patients which, for obvious reasons, correlates with lower educational levels in the general population as well. This does not explain the high rank order of the Involutional Melancholics. 4. Mobility of Patients, as Reflected by the Relationship of the State of Residence and the State of Birth of the Patient. The sample is inadequately small in the group of Involutional Melancholia and of Catatonic and Simple Schizophrenia. Notwithstanding this deficiency, the data in column 1 of the corresponding table show that, with the exception of Hebephrenic Schizophrenia and the problematic group of Catatonic Schizophrenia and Involutional Melancholia, most patients have a considerably less stable or a less sedentary background than the general population of Kansas City has, and this seems to hold true even if the juvenile population below 15 is discounted. The ratios on the right are derived by dividing the number of patients born in Missouri by the number of patients born outside that state. Array in order decreasing residential stability Hebephrenic Schizophrenia 1.10 Catatonic Schizophrenia (?) 1.00 Involutional Melancholia (?) 1.00 Simple Schizophrenia .97 Paresis .77 Manic Depression, Mixed & Unclassified .76 Manic Depression, Depressed .73 All Manic Depression .71 Paranoid Schizophrenia .68 Manic Depression, Manic (?) .64 Cerebral Arteriosclerosis .48 Senile, All Types .41
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Archiv fr die Geschichte der Soziologie in sterreich, Graz

The array fairly consistently shows that with increasing age the relative number of patients born in Missouri (viz. in the state of their residence) is decreasing. Involutional Melancholia, however, does not follow this rule, but the size of the sample makes conclusions questionable. 5. Mobility in the Family Background of the Patient, as Reflected by the Relationship of the State of Birth of the Patient and his Parents. Since in this ratio the age factor, that plays an indirect role in the relationship of residence and birth place (see above), is eliminated, more reliance can be placed on the following rank order and on the corresponding figures in column 4 and 3 of the same table. The following array is based on the ratio of the figures in column 4 to column 3 (or the number of patients born outside the state of birth of either parent divided by the number of patients born in the state of birth of one or both parents). Array in order of decreasing mobility Paranoid Schizophrenia All Schizophrenia All Senile Psychosis Paresis All Manic Depression Manic Depression, Depressed Hebephrenic Schizophrenia Cerebral Arteriosclerosis Simple Schizophrenia Involutional Melancholia Unclassified & Mixed Schizophrenia Manic Depression, Manic Manic Depression, Mixed & Unclassified 1.19 .87 .81 .80 .76 .69 .68 .68 (?) .67 (?) .64 (?) .64 .58 (?) .14

The size of the sample does not permit generalizations from the figures given for the Involutional Melancholic group, for Simple Schizophrenia, Mixed and Unclassified Schizophrenia and Manic Depressive Mixed and Unclassified. However, the high degree of mobility in the family background of Paranoid Schizophrenic patients contrasts conspicuously with the family background of patients in the Manic Depressive groups and other classifications. A second type of mobility index is derived from the ratio of the number of patients whose parents are born in different states to the number of patients whose parents were born in the same state. This ratio is more instructive with respect to the degree of heterogeneity of the patients family. Again, the small size of the sample in the Simple Schizophrenic group, in the Unclassified Schizophrenic group, the Manic Depressive Manic, the Manic Depressive Mixed and Unclassified and the Involutional Melancholic group makes generalization from these figures problematic. Array in order of decreasing heterogeneity of parentage Schizophrenia, Simple (?) 1.14 Paranoid Schizophrenia 1.00 Manic Depression, Manic .85 Hebephrenic Schizophrenia .84 Manic Depression, Mixed & Unclassified .78 All Manic Depressives .73 Paresis .71
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Archiv fr die Geschichte der Soziologie in sterreich, Graz

Involutional Melancholia Manic Depression, Depressed Unclassified & Mixed Schizophrenia All Schizophrenics Cerebral Arteriosclerosis Catatonic Schizophrenia All Senile Psychosis

(?) .67 .65 (?) .58 .58 .51 (?) .45 .44

Disregarding the questionable groups, the Paranoid Schizophrenic group again ranks highest and it differs from other types of Schizophrenia as significantly as from most other diagnostic groups. In this respect Catatonic Schizophrenia and the typical old age disorders seem to show more independence from the factor of parental heterogeneity than most of the other groups. 6. Suicidal Tendencies in Mental Patients. Patients showing suicidal tendencies were so classified it their hospital records indicate an attempted suicide or a preoccupation with suicide. Obviously. the distinction is not clear-cut in every single case so that allowance must be made for a wide margin of diagnostic uncertainty. The small size of the Catatonic and Simple Schizophrenic and the Male Involutional Melancholic group should also be taken into account. The table shows a rather unusual sex ratio of male and female patients with suicidal tendencies. With the exception the Cerebral Arteriosclerotic and the Catatonic Schizophrenic group the female patients show a higher degree of suicidal tendency than the male patients. The high male sex ratio in the non-hospitalized suicidal population is reversed in most diagnostic groups. This is particularly marked in Senile, the Involution Melancholic, and in the Manic Depressive group, particularly in the Manic Depressive, Depressed type. Taking both sexes as the basis of the rank order, the highest percentage of suicidal patients occurs in the Manic Depressive Depressed group, next follow the Catatonic Schizophrenic, the Involutional Melancholic, the Paranoid and Hebephrenic Schizophrenic group. The lowest percentage is found in the Manic Depressive, Mixed group, the Senile and Paretic group. Of some interest is also the positive correlation of .36 between the residential distribution of non-hospitalized suicidal persons and of the mental patients showing suicidal tendencies.

Appendix 1. Rates of Schizophrenia per 100,000 population, Kansas City, Mo. 1925-1938 2. Rates of Paranoid Schizophrenia per 100,000 population, Kansas City, Mo. 19251938 3. Rates of Paresis per 100,000 population, Kansas City, Mo. 1925-1938 4. Rates of Manic Depressive Psychosis per 100,000 population, Kansas City, Mo. 1925-1938 5. Rates of all Psychoses per 100,000 population, Kansas City, Mo. 1925-1938 6. Median Rents, Kansas City, Mo. 1935 7. Suicidal tendencies in mental patients, Kansas City, Mo. 1920-1938
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Archiv fr die Geschichte der Soziologie in sterreich, Graz

1 Die Originale befinden sich im Archiv fr die Geschichte der Soziologie in sterreich, Graz, Nachlass Ernest Manheim, Signatur 31/5. Zuerst abgedruckt in: Ern Ernst Ernest Manheim. Soziologe, Anthropologe, Komponist. Zum 100. Geburtstag. Katalog zur Ausstellung anllich des 100. Geburtstags an der Universittsbibliothek Graz vom 3. Mrz bis 14. April 2000. Herausgegeben von Reinhard Mller. Graz: Universittsbibliothek Graz [2000], S. 60-72. Studie aus dem Jahr 1939, die bis 1943 mehrfach berarbeitet wurde (hier eine kombinierte Version von etwa 1940 und etwa 1941). Beim statistischen Teil drften nicht alle Tabellentafeln vorhanden sein. Anm. R.M. 2 Vgl. Robert E[llsworth] L[ee] Faris / H[enry] Warren Dunham: Mental disorders in urban areals; an ecological study of schizophrenia and other psychoses. Chicago, Ill.: The Chicago University Press 1939. Robert Ellsworth Lee Faris (*Waco, Tex. 1907, Seattle, Wash. 1998), amerikanischer Pdagoge und Soziologe. Henry Warren Dunham (*1906, Ludowici, Ga. 1979), amerikanischer Soziologe. Anm. R.M.