A DESCRIPTIVE ECOLOGICAL STUDY OF SELECTED FIRST ADMISSIONS

TO A PRIVATE PSYCHIATRIC HOSPITAL I960 THROUGH 1963

APPROVED:

Major Professor

Minor Processor

* r / / ' ^

Blre

A DESCRIPTIVE ECOLOGICAL STUDY OF SELECTED FIRST ADMISSIONS

TO A PRIVATE PSYCHIATRIC HOSPITAL I960 THROUGH 1963

j. £!£'£> J. S

Presented to the Graduate Council of the

North Texas State University in Partial

Fulfillment of the Requirements

For the Decree of

MASTER OF ARTS

Hv

Fr.ede.ric Carroll, a. S., B, A.

IJei'.i.. On ) s

Kay} 3.96B ' .

TABLE OF CONTENTS

• ' Page LIST OF TABLES . i v

LIST OF ILLUSTRATIONS . . . . . . . . . . . . vi

Chapter

I. INTRODUCTION . . . . . I Statement of the Problem Selection of Variables Purpose and Limitations of the Study

II. SOURCES OF THE DATA. . . . . . . . 20 Organization of the Data Classification of Cities Definition of Terms

III. ANALYSIS OF THE DATA . . . . . 34 Geographic Region by Birthplace Age of Patients at First Admission ' Diagnostic Categories A.ge arid Diagnostic Categories Spatial Mobility Occupational Categories Occupational said Diagnostic Categories Metropolitan Status and Size 2 o n e s of Re sidenc e Sur;;.r:iary of Findings

IV. CONCLUSION • . . 85

APPSKDjT

eiCLiOGRAPBT ' . lij

X. Percentage Distribution of West South Central Population by Occupation and Diagnostic Category . . . . . . . . . . 47

XI. Percentage Distribution of Population Based on Metropolitan Status and Size by Age 55

XII,. Percentage Distribution of Population Bs.sed on Metropolitan Status and Si ze and Diagnosis , . , 56

XIII. Percentage Distribution of the Schizo-phrenic Category by Metropolitan Status and Size and Age 57

XIV. Percentage Distribution of Population by Metropolitan Size and Status

r and Occupation , , , , p

XV, Percentage Distributions by Occupational Groupings According to Metropolitan Status and Size by Diagnostic Groupings . , 60

XVI, Percentage Distribution of Population Based on Zone of Residence by.Age Groups 65

XVII. Percentage Distribution of Population Based on Zone of Residence and Diagnostic Categories . . 66

XVIII. Percentage Distribution of Population Based on Zone of Residence, by Age and by Diagnostic Categories . . . . . . 65-69

XIX. Percentage Distribution Based on Zonal Groupings, by Age and by Diagnostic Categories * . . . . . . . . . . . . . . . 71

XX. Percentage Distribution of Population Based on Zone of Residence by Occu-

• pational Groupings . . . 73

XXI, Percentage Distribution of Population by Occupational Groups, Zone of Resi-dence, end Diagnostic Category 75-7$

X.

XI,

XII.

XIII.

XIV.

:v.

XVI.

XVII

XVIII,

XIX.

XX.

Percentage Distribution cf West South Central Population by Occupation and Diagnostic Category . . . . ,

Percentage Distribution of Population Based on Metropolitan Status and Size by Age v ,

Percentage Distribution of Population Based on Metropolitan Status and Size and Diagnosis . . .

* 9 »

Percentage Distribution of the Schizo-phrenic Category' by Metropolitan Status and Size and Age . . . . ,

Percentage Distribution of Population by Metropolitan Size and Status and Occupation

Percentage Distributions by Occupational Groupings According to Metropolitan Status and Size by Diagnostic Groupings

Percentage Distribution of Population Based on Zone of Residence by,Age Groups

Percentage Distribution of Population Based on Zone of Residence and Diagnostic Categories , .

* • 3 • * # »

Percentage Distribution of Population Based on Zone of Residence, by Ag and by Diagnostic Categories * . * # « . 58 6'

Percentage Distribution Based on Zonal Groupings, by Age and by Diagnostic Categories

Percentage Distribution of Population Based on Zone of Residence by Occu-pational Groupings

XXI. Percentage Distribution of Population by Occupational Groups, Zone of Resi-dence, and Diagnostic Category . . rj r

47

55

56

57

5&

60

65

66

^ G *Qy

71

73

,.rrA

LIST OF ILLUSTRATIONS

Figure ' Page

1. Zones of Residence . . . . . 64

• CHAPTER I

INTRODUCTION

Statement of-the Problem

Mental illness is now veil recognized as a social

problem, rather than just a personal or family misfortune.

Mental illness qualifies as a social problem from two dis-

tinet points of view:

One usually recognized aspect of the social problem of

mental illness is the attempt to gauge the economic and

sociological impact upon ~he community and the society and

to ascertain what social measures might "be taken to alleviate

the effect .of this impact.

But, an ever more important aspect arises fox1 today's

sociologist: The i'acc that medicine as a science has not

fully succeeded in isolating The causes of some types of

menta.„ illness—most particivi&rly those disorders for which

no organic origin has been established, .i .je., the so-called

functional disox'a-srs^—leads to speculation on the possibiliti.es

""iiobert £. L. Faros and-K. Warren Dunham, Mental Bis-orders in Urban -reas (Chicago, J939). p. xi.'

of finding causes through other approaches (than medical

science).

It is now obvious that it was a most signal moment when

men decided mental illness was' illness and thus properly

within the academic domain of medical science, bringing

about great and humane advances in all the aspects of mental

illness: discovery, treatment, causes, and hopefully, pre-

vention. Although this decision is relatively new, the

achievements of medical science in this specialized' field

of medical study are impressive and important.

So impressive and important, as a matter of fact, that

a tendency has arisen to consider that only medically trained

scholars might be permitted to work in this area. This brand

of academic near-sightedness is not unique to this particular

situation. It is a common enough phenomenon to note that

scholars .frequently assume that academic boundaries are some-

how innate and irrevocable, rather than purely arbitrary,

originally ari'-anged as a matter of momentary convenience and

thus subject GO constant revision and change as the frontiers

of all disciplines expand. Recent academic history has been

that of discovering many areas-~not just points—but broad

areas of impingement of one discipline upon another, or

several others.

Social scientists have turned attention to unsolved

p~ro~'o 10ms Drevxously thought to • • e within some utner ju.ris—

diction. Mental illness is a most recent example. The

sociologist is now attempting, to examine social data both

for a knowledge of the causes of certain types of mental

"i 11ness and. i'or a better urQerstano.irg ^f tn.e true and exact

nature of these disorders which still baffle the medical

scientist. The sociologist interprets mental disorder as

one manifestation of personal disorganisation resultant from

2

an individual's iiislajusted social relations.

Burgess suggests that "communication is essential, for

normal human development and that social isolation makes for mental br-r e a k d o w n . H e adds that a sociological theory

of this sort "offers- no direct explanation of alcoholic psy-

choses. dementia paralytica, and other organic types of men-

tal d i s o r d e r . B u t , those psychoses which have been termed

"functional," even though they may be "functional" only in

the sense that no organic origin can presently be ascribed

to there, have ceeri shown in several studies, most prominently

. p. xixi.

.»•* ; •""%-} T \ V l k. * a-~ w l «

4

by Faris and Dunham in their Mental Disorders in Urban Areas,^

to be susceptible to sociological explanation.

And among sociologists, those who look to human ecology

for answers to some of our many riddles have begun to search

for some enlightenment by examination of ecological data.

Burgess reports that, as early as 1925,

Previous urban studies have demonstrated a dynamic association between the spatial pattern of the city and its moral or social order. They define and describe the city as an entity consti-tuted by the interrelations and integrated of its component communities, each of which (1) occupies a territorial area, (2) possesses a specialized function, (3) selects a population with charac-teristic composition by age, sex, occupation, economic class, and nationality and racial stock, and (4) develops a typical cultural and political order.

More recently, Hawley points out that the community is

the "subject of ecological enquiry"? and that ecology studies

the community's form and its development from an especial

frame of reference: "the limiting and supporting factors

A of the environment."" But he points out that man "is capable

5lbid,

^Ibid., p. xvii

'Aruos H. Hawley, Human Ecology: A Theory of Community Structure (New York, 1950)", p. ~6?. "

8 Ibid., p. 6?.

of an extraordinary degree of flexibility and refinement

in behavior"^ thus differentiating human ecology from ecology

as applied to all of life. Therefore, reasons Hawley,

MacKenzie's definition of human ecology: "Human ecology

deals with the spatial aspects of the symbiotic relations

10

of human beings and human institutions,"" is far too narrow.

Human ecology is definitely, and primarily, a sociological

concern, in Hawley's view, for the human community's develop-

ment and orgnization must be envisioned, and described with

regard to the functional, psychological and moral integration

of man's collective life; the inextricable interweavings of

sentiment, systems of values, conceptual constructs, sus-

tenance activities and the relationships arising from these 11

activities must all be accounted for. In short:

The question of how men relate themselves to one another in order to live in their habitats yields a description of community structure in terms of its evert and measurable features.

Following Hawley's point of view regarding the definition

and inclusiveness of human ecology, ecological data must include

°rtdd., p. 6&.

x^Ibld., p. 69.

•^Ibid. , p, 73.

12! [bid., p. 74,

both a population and its characteristics and some measure-

ments of the environment of zhis population. Following

Hawley, an ecological investigation must select from available

data and examine at least some of the relationships that may

exist among these measurable population and environmental

characteristics, in an effort to find and isolate the causes

of mental disorders, particularly of those noxv called "func-

tional." *

Selection of Variables #•

The actual selection of variables to be included in

any such investigation is, perforce, governed largely by

availability. Concomitant with availability, pertinence

is a principal limiting factor in this selection of variables.

Pertinence," that is, as determined'by the aim and the inten-

tion of the study,

It is the aim of this particular1 study to describe the

results of examining certain selected ecological data (and

the relationships among them) presently available on partic-

ular first-admission palients to a private psychiatric

hospital during the years I960 through 1963.

In studying this population the independent variables

which were selected are city of-'residence (of the individ-

ual patient within the studied population), the distance of

7

this city from the hospital, the size of this city, and the

birthplace of the patient in terms of geographic region

within the United States. The dependent variables selected

are the patientTs diagnosis,'his age, and his social class

as indicated by his occupation.

John A. Clausen?s recent (1956) report^ to the American

Sociological Association shows the current widespread interest

in this type of investigation. Clausen's report recognises,

among the various possibilities available to the sociologist:

Studies of the differential prevalence or inci-dence of treated mental illness within segments of a population defined:

a, Geographically—that is, ecological distributions of mental illness,

b. In terms of social and cultural char-acteristics—for example, social class distributions, migrants vs. natives,

and so forth. ^

His report comments on the fact that most ecologically-

oriented studies have used hospital records of first admis-

sions as indices of the various psychoses for a specified

time and area. Supporting the adequacy of such a criterion,

Clausen states, "In urban America, most, though by no means

all, psyehotics may be expected to be hospitalized if they

13John A. Clausen, Sociology and the Field of Mental Health (New York, 1956). ~

14Ibid., p. 22.

become acutely disturbed and if rhis phase of their mental

illness is of long duration.

The fact that Clausen's central concern is not to report

any specific findings, nor to furnish a particular socio-

logical description, but to survey what sociologists are

presently doing in this field and what they may expect in

the way of opportunities and requirements for the future

provides basic justification fox1 entering an investigation

of this sort. The patients' records to be examined here

will be limited to first admissions.

As early as 1940, Stuart A. Queen called for more

studies of this nature. Queen, in an examination of Faris

and Dunham's work in Mental Disorders in Urban Areas, con-

cludes that ecological data do tend to indicate the areas

where psychotic disorders most frequently appear and do

tend to establish some measure of relationship among the

various statistical measures available on patient populations.^

Burgess finds the hypothesis that social isolation is

a precondition for mental disorder to be valid. (This

~L"Ibld,. , p. 24.

loStuart A. Queen, "The Ecological Study of Mental Disorders," American Sociological Review, V, 1 (February. 1940), p. 2077 ~

isolation is thought to occur vrfien essential communication

is lacking. The choice of the size of the patient's

city of residence as one of the variables to be studied

was directly influenced by certain comments by Burgess:

Mental disorders appear to be more prevalent where the population is mobile and heterogeneous than where it is stable and homogeneous and where life conditions are complex and precarious rather than simple and secure. °

Social conditions, while not primary in causation, may be underlying predisposing and precipitating fac-tors. Situations involving stress and strain of ad-justment—.such as those of isolation, of migration, of love and marriage, and of frustration in a career, may, in the case of persons constitutionally predis- ' posed, make for mental conflict and mental break-down. 1 J

. . .urban areas characterized by high rates of social disorganization are also those with high .rates of mental disorganization.^^

The smaller city, more communal than associational in

its social make-up, is known to provide greater stability

of the social matrix for its residents and is usually pro-

ductive of the simple, secure conditions of life essential

to a high degree of social organisation; the larger city,

associational in its essential character, characterized by

--^Robert E. L. Faris, op. cit., p. xi.

18Ibid., p. xii.

-*-9ibid., p.- xvi *

20Ib id., p. xvili»

J

, -p

10

mobility and hetzy v-.ry same token

more productive of the;- complex. precarious conditions o:

life more conduci 'e to a high degree of social disorgani-

zation. For thes-- reasons, then, the sioe of the city of

patientsT residence 1? considered pertinent to this study.

The distance of the city of residence from the hos-

pital was selected in order to examine, to some extent,

the pattern of distribution of functional mental disorders

in the area served by the hospital, Dunham noted, in 1947?

that such disorders showed a marked pattern of distribution

in the C h i c ag o are a, namely:

1. A larger incidence toward the center of the city,

diminishing in a gradient toward the smaller incidence

noted in the outer zones.

2. Incidence rates and distribution patterns for

schizophrenia resemble those for mental disorders generally.-—

This was, of course, a reiteration of his earlier

remarks to this same effort during his collaborative work

with E. L. Faris.^

2^-H. Warren Dunham, "Current Status of ecological Hesearon in Mental Disorders," Social Forces, XXV (March, 1947 ) j p. 323'.

Paris and Dunham, kenta.l hj s:• rders, p. 173-

11

Clausen's report, as previously cited, recommends

study of the geographical distribution of mental illness

among the "segments of a p o p u l a t i o n . " 2 3

In order to search for some evidence of mobility in the

studied population, the birthplace of the patient.(in terms

of geographic region) -was selected as still another ecolog-

ical variable,, This selection, again, was prompted, in

part, by Clausen's report, in which he cites "migrants vs.

natives" as one of the "social and cultural characteristics"

amenable to examination by the sociologist.

Faris and Dunham show a concern for mobility in their

definitive work, Mental Disorders in Urban Areas, stating,

"the higher rates of schizophrenic reactions appear to be

related to areas of high mobility,"2^ and again, "especially

significant is the connection between the rates of schizo-

phrenia, excepting the catatonic type, and indices of

mobility,"25

In selecting dependent variables, the patient's diag-

nosis (upon admission) was obviously the first considered,

this study being an ecological description of certain mental

John A. Clausen, og_. cit., p. 22.

"PI

Faris and Dunham, Mental Disorders, p. 173 r*j £*

^Ibid, , p . 1 7 7 -

12

illness patterns. The actual number of individual diagnoses

available for study is so large that a bewildering complexity

would result were each such diagnosis treated distinctly.

In order to reduce the number of diagnoses to a manageable

number and simultaneously standardize the study with others,

the various diagnoses were grouped in accordance with the

recognized procedures established by the American Psychiatric

Association and published in their diagnostic and statistical

manual.^ This, then, provides diagnostic data meaningful

to the social scientist and comparable to other social

studies using broader terms such as "schizophrenic reactions"

rather than such detailed, medically meaningful, but too

closely associated terms such as schizophrenic reaction—

childhood type, juvenile type, obsessive compulsive type,

and the many other sub-types which can be combined under

one category.

In keeping with the previously cited criterion regarding

organic and functional types of mental disorder (see page

26 The Timberlawn Foundation lists 745 distinct diag-noses in its Diagnostic Code.

^American Psychiatric Association, Diagnostic and Statistical Manual: Mental Disorders, prepared by the Committee on Nomenclature and Statistics of the American Psychiatric Association (Washington, 1952).

13

one, footnote number one), on!j_y those diagnoses considered

as "functional" were sele.ctecjl for examination.

The fact that the origin of functional disorders remains

obscure to both the medical and the social scientist prompts

the selection of age as another of the variables to be con-

sidered. Hawley points out that, "It is generally agreed

that physiological age. . .is an important limiting factor

on what an individual, is capable of doing." Investigation

*

of the limitation imposed by;this factor is reflected through-

out Faris aji'd Dunham's extensive study of the Chicago area

in which many of their tabulations are broken down into

age brackets.^9

Nevertheless In selecting age as meaningful to the

study, it was apparent that arbitrary limitations must be

imposed. Faris and Dunham indicate that old age consti-

tutes a separate study and ig productive of a number of

diagn o s t i c c omp1i c at i ons:

The senile psychoses are similar to other clinical classification^ which have been examined, inasmuch as there are np adequate and objective criteria for classifying them. Here, also, the

2$ ' 'Amos H. Hawley, "An Epological Study of Urban Service

Institutions," Studies in Hu|nari Ecology, edited by George A. Theodorson {Evanston", ~196]L) 7 p. ".192.

29 Faris and Dunham, Mental Disorders.

14

etiological basis is still obscure. Some psychia-trists insist that senile psychosis is in reality late schizophrenia; others point to tissue changes of the brain cells as the causative factor while at the same time stressing the part played by heredity. Certain factors, largely social in origin, such as old age dependency, the isolation of the aged, sud-den changes in the aged person's routine of 3,ife, and the disintegration of families, also tend to make the problem of diagnosis more difficult. Some psychiatrists recognize this fact and warn that mere senility must be distinguished from the symp-toms of a real senile psychosis.

These complications have been avoided in this study by

restricting the age group of patients in the population

to be examined to the maximum age of 60 years.

By the same token, the extremely young (those below

the age of 25 years) have also been eliminated in order to

confine the study to adults. Other, more extended studies

demonstrate certain differences between.young and old which

would necessarily lead this study beyond its intended scope,

were they to be considered and dealt with. DeeTs study of

Q 1

St. Louis-'' effected a similar limitation by setting a

lower limit of 21 years in selecting the studied population.32

^Queen, op. cit. , p. 205-

-^William L. J. Dee, r'An Ecological Study of Mental Dis-orders in Metropolitan St. Louis," unpublished master's the-sis, Washington University, St. Louis, Missouri, 1939, cited in Queen, ojo. cit., p. 201.

^Queen, op. cit. , p. 203 .

15

Hollingshead and Redlich have raised the question,

33

"Is mental illness related to social class?"" This question

becomes one of the central questions in their extensive

research supporting their recent (195$) book, Social Class 34

and Mental Illness. They state that this query is

. . .related to the etiology of mental illnesses. The psychodynamic concept of unconscious conflict between instinctual forces and the demands of the environment is crucial for many attempts at explan-ation of most neurotic and psychotic illnesses. Knowing that the different social classes exhibit different ways of life, we conjectured that emotional problems of individuals might be related to the pat-terns of life characteristic of their class positions.

Not only is it beyond the scope of this study to attempt

too piercing or rigorous an investigation of the social class

status of the individuals involved, but it is also beyond the

scope of the data which are available for these patients;

neither income data nor residential street addresses.were

available on these patients. Nevertheless} in order to per-

mit some reflection of social class in the study, patient's

occupation was included as one of the selected variables.

Occupation is well recognized as a principal indicatqr of

33 ^August B. Hollingshead and Fredrick C. Redlichj, Social

Class and Mental Illness (New York, 1958), p. vii.

3'+Ibid. , p. 10.

35'ipid ., p. 10.

16

social class in the United States. Chinoy notes, "In almost

all of the available studies, occupation is reported as a

36 major determinant of status.""^

Purpose and Limitations of the Study

An examination of some of the relationships among these

variables will be conducted in order to provide a purely

descriptive, ecological study of an available population—

37 an elementary study along the lines recongized by Clausen

as sociologically productive, and of the sort called for by

3 $

Queen. In spite of its limitations, such a study can pro-

vide some additional sociological data of the type previously

discussed in this chapter. The limitations are manifold:

Total prevalence of mental illness in the population

served by the one private, psychiatric hospital considered

in this study is not readily available. The private hospital

may admit patients without regard to legal residence; the

private hospital may or may not compete with other private

hospitals of considerable, prestigious reputation over an

area that defies definition. To make a comparison between

36E1y Chinoy, Society: An Introduction to Socioloev (New York, 1963 ), p~ 151". ' " ' ~

^ H -'•'Clausen, od. cl t. , p. 22,

->°Queen, od„ ait», p. 20?.

17

public and private hospitals on the basis of "population

served1' could become a complex study in itself.

The private psychiatric hospital does not in itself

represent the entire community to the extent that a public

hospital usually does. This study will analyse some selected

characteristics of the population which this type hospital

does serve. But, in the case of the particular hospital

considered in this study, there are two outstanding factors

which prevent this hospital's being considered as representa-

tive of the community as a whole, namely:

(1) The average hospital expense (at this particular

establishment) is presently in the range of $250 to $32$

39

per week.

(2) The data are concerned only with in-patients.

Although out-patients are treated by the hospital under

study here, the hospital is so organized that the records

of such patients are handled separately and are not included

in the admissions records available for this study. Since

it xs a common practice in publicly supported mental hos-

pitals to accomplish as much active treatment as possible

39 Introduction to Timfcerlawn Sanitarium. (Dallas,

1964), p. 11. " " — — —

18

on an out-patient basis and to include .these out-patients

in totals reported for statistical purposes/4^ care must be

exercised in making any comparison between the information

developed in this study and information furnished by a study

of public facilities.

Still another stumbling block in the application of

ecological methods to the available data is the possibility

that the home address.shown in the records may not always be

correct. Queen notes that the recorded address may actually

be that of the next-of-kin, or even the address of an insti-

tution from which the patient was transferred.^1 These data

do not deal with extreme long term hospitalizations, and are

at least more likely to be free of this latter type of error,

but there is actually no means to ensure that next-of-kin,

most frequently the patient rs escort at the time of admis-

sion, do not give their own addresses even where this may

differ from the patientfs actual, most recent address. Too,

the most recent address, even where correctly given, may be

so recent as to be meaningless in terms of the patient's

environmental background. It can only be said that this

40Ibid., p. 16.

^Dunham, "Current Status," p. 325.

19

study may be less encumbered with this sort of error than

studies which involve public .hospitals, due to the greater

financial stability of the patient's families represented

here. Hospitalization of these patients may be .'less likely

to result in the breakup of the home and the loss of a

permanent address for the patient and family alike as would

be the case for families of lesser means.

CHAPTER II

SOURCES OF THE DATA

This study will be based upon data which were supplied

by the Timberlawn Foundation of Dallas, Texas. This foun-

dation, organized in 195$, operates in close conjunction

•with the Timberlawn Sanitarium, also of Dallas, a private,

psychiatric hospital exclusively for the treatment of poten-

tially recoverable mentally ill patients.

The Timberlawn Sanitarium was established June 23, 1917.

Presently, it is a member of the American Hospital Association

and the National Association of Private Psychiatric Hospitals,

and is accredited by the Joint Commission on Accreditation

of Hospitals, in addition to being licensed by the Texas

Department of Public Health.

The sanitarium comprises 140 beds, entirely devoted to

the treatment of mental illnesses of all sorts, with the

specific exception of narcotics addiction. All beds are

assigned to either single or double rooms, as there are no

wards in this hospital. The hospital is located a few miles

to the east of downtown Dallas and still well within the city

limits. A complex of approximately a dozen separate buildings

21

houses the various departments, the treatment and hospitali-

zation facilities and the administrative organization.

Also the sanitarium regards the psychiatric nursing

staff, their departments of occupational therapy, recreational

therapy, social work, and psychology as a treatment team

working in conjunction with the staff physician. The inte-

grated patient care resulting from the coordinated efforts

of the treatment team is termed Milieu therapy by the hospital.

Technically speaking, the hospital is a part of the

Timberlawn Psychiatric Center which includes the Day Hospital

and the Out-Patient Department (although neither of these-

facilities are included, in this study) and the Timber lawn

1

Foundation. And it is the Tiraberlavm Foundation which has

actually provided the data basic to this study. The foun-

dation is a private, nonprofit organization established for

the purpose of promoting medical science, with especial

attention to the development of psychiatry and related behav-

ioral sciences.^

1AZL Introduction to Timberlawn Sanitarium, (Dallas, 1964), p. 16.

^Timberlawn Foundation Sixth Annual Rer>ort. (Dallas. 1964), p. 8. ""

22

Initially, the Timberlawn Foundation undertook the

project of codification of all the case histories of in-

patients served by the hospital since its founding in 1917.

This comprises 17,000 case histories containing not only the

predictable medical and diagnostic information, but some

3

social history also.

A recent grant from the National Institute of Mental

Health has enabled the foundation to make available a com-

plete set of computer cards, specifically designed for this

study: the case histories of all first-admission, male

patients, aged 25 through 60, for the years I960 through 1963.

In selecting this propulation for study, the limitations

mentioned on age and sex were placed in an attempt to elimi-

nate, insofar as practicable, non-workers and others possibly

prone to accept, or even soek, hospitalization without regard

for the dissipation of their productive years. This selection •

is reflective of an assumption that males in the selected age

group, 25 through 60 years, will only resort to hospitalization

as an ultimate measure in the treatment of mental disorder,

whereas women might conceivably accept hospitalization as a

preferable form of treatment somewhat more readily. Some

3 The code Is set forth in The 'Umberlawn foundation

Source Document, IBM Card Structure Code" Book.

support for this assumption can be noted in the following

considerations: During the time span considered by this

study, 2136 first admissions were made at Timberlawn of out-

patients. Of these 2136 patients, only 637 or 29.$ per cent

were males. By contrast, the United States Public Health

Service reports that, on a nation-wide basis, men are hospit-

alized for mental illness at a slightly higher rate than

women.^ Hopefully this limitation in the selection will limit

the study- more closely to persons genuinely in need of profes-

sional assistance in coping with the demands of society.

The limitation imposed upon the time span to be consid-

ered by this study is an attempt, in part, to counteract the

age-old problem of errors and inadequacies in the data. Queen

warns that differential diagnosis by different psychiatrists

is a particularly difficult problem to deal with in a paper

5

concerned with one or more mental disorders. Singer makes

note of the fact that the classifications themselves are

^Characteristics of Patients in Mental Hospitals, (Washington, D. C., 19657, pp. 4-5.

^Stuart A . Queen, "The Ecological Study of Mental Disorder," American Sociological Review, V, 1 (February, 1940), p. 203,. " '

24

only a matter of temperacy convenience0 and thus subject to

change and productive of error through lack of standardi-

zation. But the Timberlawn Foundation reports that, during

the selected period, I960 through 1963> the personnel of the

hospital, both medical and administrative, underwent compara-

tively little change. Too, these later years (among those

available for study) constitute a period of greater sophisti-

cation and training by both the administrative and medical

personnel of the hospital; diagnosis and record-keeping alike

should reflect the benefit of a more scientificallv oriented

personnel. The establishment of the research foundation (in

195$) should have, by I960, motivated a more conscientious

application to accuracy. Finally, the consideration of time-

liness of the finished study dictates a selection from the

more recent years.

The original selection limitations produced a total of

425 patients' histories available for examination and study.

However, in the process of organising the data, all but those

case histories diagnosed, as functional in nature were elimi-

nated from the final population to be studied; this reduced

^Robert E. L. Faris and H. Warren Dunham, Mental Dis-orders in Urban Areas (Chicago, 1939)> p. xi.

25

the number of cases to 3̂ -9. This process is explained in

the immediately following pages.

Organization of the Data

The organization of the original data from Timberlawn

provided for the coding of 745 distinct diagnoses. Both to

render an analysis of the data less cumbersome and to effect

a measure of standardization with other studies, these diag-

noses have been grouped, as previously mentioned, in accord-

ance with the standard nomenclature of the American Psychiatric

Association. This grouping resulted in the following cate-

gories:

Acute Brain Disorder Chronic Brain Disorder Psychotic Disorders other than Schisophrenic Psychoneurotic Reactions Personality Disorders No Coded Diagnosis

(A detailed listing of the various disorders grouped under

each of these categories will be found in Appendix A to this

study.)

A preliminary study of the data revealed the breakdown

of the patients among the categories as shown in Table I.

n 'The Timberlawn Foundation lists 745 distinct diagnoses

in its Diagnostic Code.

26

From this preliminary examination it was determined

that, as a result of vsritVlng all cases not diagnosed as

functional (17.9 per cent), including the organic diagnoses -

TABLE I

PERCENTAGE DISTRIBUTION OF MALE FIRST ADMISSIONS, 25 THROUGH 60 YEARS OF AGE, I960 THROUGH 1963

BY DIAGNOSIS

Diagnosis Per Cent

Schizophrenic reactions , 42.3

Psychotic disorders other than schizophrenic . . . 13.6

Psychoneurotic disorders 12.9

Personality disorders . . . . . . . . . . . . . . . 13-3

Acute brain disorder . . . . . $.?

Chronic brain disorders . . . . . . . . 3.2

No coded diagnosis 6.0

Total N=425 . . . » 100.0

of acute and chronic brain disorder (11.9 per cent) and the

cases involving no coded diagnosis (6.0 per cent), the actual

population to be studied would number 3'49 cases or 6-2.1 per

cent of the total first admissions in this age group during

this period.

Again,.the occupations of the patients involved in

the study were classified Into groups. These groups and the

27

percentages of the population tc be studied in each group

are shown in Table II.

TABLE II

PERCENTAGE DISTRIBUTION OF MALE FIRST ADMISSIONS, 25 THROUGH 60 YEARS OF AGE, I960 THROUGH 1963

BY OCCUPATION

Occupation Per Cent

Professional „ . . . 19.5

Farmers and farm managers 6.9

Proprietors . . , . . 22.1.

Clerical . 22.6

Craftsmen . $ .9

Operatives . . . . . . . . . . . . . 4.0

Service workers . . . . . . . . . . . . . 1,4

Laborers 2.6

Students , . 1.7

No occupation . . . . . . . . . . 4„6

Other miscellaneous 3,7

Not ascertainable 2,0

Total N=3 49 100.0

A complete listing of the various occupations grouped

into each oi these classifications wi 1.1 be found in Appendix

B to this study.

23

^ P,

rm.

Classification of Citi

:he cities of residence (of the patients) have been

d

classified in accordance with accepted ecological practice,

for convenience in interpretation of the data and in order

to effect a standardization with other studies and other

data. The classifications used and the percentages of the

studied population found in each classification are as

presented in Table III,.

TABLE III

PERCENTAGE DISTRIBUTION OF MALE FIRST ADMISSIONS, 25 THROUGH 60 YEARS OF AGE, I960 THROUGH 1963

BY METROPOLITAN STATUS AND SIZE

Metropolitan Status and Si&e Per Cent

Metropolitan 50,5

Ping cities . 16,1

Independent IS .6

Rural . . . . . . . . . . . 5-4

Not Ascertainable 9.4

Total N-349 . . .100.0

Jeffrey K. Hadden and Edgar F. Borgatta, American f,-i -hi PS- rP]-l O "1 V* ̂ r\ O 1 PVlovin n+- ~ .. - ' ̂ - - - -- - -> y-y r- S V

29

The rural classification includes towns and villages

or other places with a population of 2,500 or fewer persons.

The independent classification includes all cities with a

population in excess of 2,500 but not more than 50,000 and

presumedly ecologically independent of some major or central

city or metropolis. This presumption is exercised when the

city is not located within standard metropolitan statistical

area. The ring cjLtjr classification includes those cities

of the same size bracket as independent cities, but located

within the limits of a standard metropolitan statistical •

area, or "in the ring.1'^ The metropolitan classification

includes those cities with a population in excess of 50,000,

whether located in a standard metropolitan statistical area

or riot. The not ascertainable classification consists of

those patients whose home address could not be identified in

the process of coding. A list of the cities encountered in

this study showing their classification will be found in

Appendix C.

The cities have also been classified in terms of dis-

tance from Dallas (the site of the hospital), following a

system, of zones established by the Timber lawn Foundation in

the process' of coding the data. These residential zones and

the percentages of patients found in each z-onp. ars

30

?j\BL5 IV

.PERCENTAGE DISTRIBUTION OF MALE FIRST ADMISSIONS, 25 THROUGH 60 YEARS OF AGE, I960 THROUGH 1963

BY DISTANCE OF RESIDENCE FROM DALLAS

No. Residence Zone • Per Cent

1. City of Dallas 35.3

2. Dallas County 11.5

3. Under 50 Miles (from Dallas) 10.9

4. 50 to 100 Miles 8.1

5. 101 to 200 Miles 9.5

6. 201 to 300 Miles . 4.3

7. 301 Miles and Beyond „ . . . 10. $

6. Contiguous States 7.7

9. Non-contiguous States . . . . . . . . . . . . 1.7

10. Not Ascertainable 0.2

Total . N=349 100.0

Each larger zone excludes the territory and the patients

residing in the small zones; zones 5, 6, and'7 do not Include

any territory outside the borders of the state of Texas. .The

contiguous states include all patients from New Mexico,

Oklahoma, Louisiana, and Arkansas regardless of actual mileage

from Dallas.

31

The birthplace of each patient was originally coded

only in terms of the geographical regions of the United

States as defined by the U. S. Bureau of the Census." A

list of the states in each region will be found in Appendix

D to this study. This scheme has been retained, both to

make use of readily available data and to maintain standard-

ization with the census bureau1s terminology. The regions

and the percentages- of the studied population in each are

given in Table V.

A simple treatment of patients1 ages by actual years

would certainly produce unwieldy and cumbersome tabulations;

therefore the ages of the patients were grouped within their

respective decades following several examples used and cited

11 by Hawley in presenting percentages of age distributions.

,U. S. Bureau of the Census, Statistical Abstract of the United States: 1964, No. 85 (Washington, D. C., 1964), pp. xii, 50.

^~F. W. Notestein, e_t al., The Future Population of Europe and the Soviet Union (Geneva, 1944), Appendix IV, and Sixteenth Census of the United States, Population, United States Summary (Washington, D. C., 1943), Table 7, cited in Amos Hawley, Human Ecologyi A Th_eory_ of Community Structure (New York, 1950), pp. 134, 136-137." "" " ~

32

TABLE V

PERCENTAGE DISTRIBUTION OF MALE FIRST ADMISSIONS, 25 THROUGH 60 YEARS OF AGE, I960 THROUGH 1963

BY GEOGRAPHIC REGION OF BIRTHPLACE

No. Geographic Region Per Cent

1. New England 1.1

2. Middle Atlantic O.S

3. East North Central . . . 4.6

4. West North Central . 5.2

5. South Atlantic . . . . . . . . . . . . . . . . 3.2

6. East South Central . 2.0 '

7. West South Central . . . . . . . . . . . . . . 69.1

8. Mountain 0.2

9. Pacific 0.5

10. Outside of the United States ..." I,$

11. Not Ascertainable . . , . 11.5

Total N=349 . . . . . . . . . . .100.0

Definition of Terms

The larger part of the terms essential to an under-

standing of this study has been defined in the process of

describing the selection of the variables, the sources of

the data and the organization of the data, with the following

exceptions:

33

Age, as used in this study, is defined as the patient's

age at the time of admission to the hospital; for simplifi-

cation of the analysis the individual ages have been combined

within decades.

In classifying cities according to the size of popu-

lation, I960 census totals of population are used.

Patient, when not specifically stated otherwise, refers

only to in-patients- who have been actually hospitalized.

And finally, "hospital population" or simply "population"

where used in the succeeding chapters of the study, is defined

in the strict statistical sense as distinctly applied to this

particular study, jL.es., the male patients, aged 25 through

60 years, admitted for the first time to the Timberlawn

Sanitarium, during the years I960 through 1963, for treatment

for functional disorders.

CHAPTER III

ANALYSIS OF THE DATA

In an attempt to make some small contribution to the

solution of the problem as stated In Chapter I,, and using

the data from the source described in Chapter II, these data

will be analyzed. In analyzing the data, comparisons will

be made with the findings of other more comprehensive

studies: partially to confirm these earlier findings, but

more importantly to examine the present data, to discover-

to what extent these data conform to previously determined

patterns in the prevalence of mental disorder and to what

extent anomalous situations may exist. In following this

analysis, the previously discussed limitations of this study

must be borne In mind at all times.

Geographic Region by Birthplace

Analysis of the data in terms of the geographic region

of the patientsT places of birth reveals little evidence of

mobility in the patients* histories. With 69.1 per cent

(see Table Y) of the total population showing a place of

birth in the West South Central region (Arkansas, Louisiana,

35

from any of the other' geographical, regions, this West South

Central segment of the sanitarium'? population should be

examined in terms of further controls.

Age of Patients at First Admission

In Appendix E the distribution of the population accordin,

to places of birth (Table V) has been controlled for age by-

decades. In Table VI the West South Central segment of the

population is shown separately, distributed according to

these age brackets.

TABLE VI

PERCENTAGE DISTRIBUTION OF POPULATION DERIVED FROM WEST SOUTH CENTRAL REGION

BY AGE AT ADMISSION

Age at Admission ' Per Cent

II. 25-29 . . . . . . .

III. 30-39 . . . . . . . . . . . . . . 34.8

IV. 40-49 2a.3

V. 50-59

VI. 60 . . . . . . . . 2.1

Total N-241 . . . . . . . . . . . . . . . . . . . . 100,0

The majority of the cases, 63.1 per cent, are found

between ages 30 and 50. [he underrepresentation (17-4 per cent)

36

"of first admissions in r,heir 20fs is, of course, at least

partially due to the fact that only a five-year period is

included in the population. The fifth decade, again showing

only 17-4 per cent, partially a measure of survivorship, is

equally underrepre-sented. Exempting those 30 to 50, all the

ether age brackets taken together account for only 36.9 per

cent of the population, a figure roughly equal to the per-

centage in their 30Ts and only s-lightly exceeding those

patients in their 40Ts.

This frequency distribution parallels rather closely

the .findings of Paris and Dunham in their Chicago study.

Their findings in the Chicago area show that the combined

ages 30 through 49 greatly outnumber all other decades

togetner in the cases of distribution of male schizophrenics,

manic-depressives, and undiagnosed psychotics. In their

study, manic-depressives in the fourth age category (29-4

per cent); similarly the undiagnosed psychotics show 30.4 4-

pei* cent in the fourth category and 25.3 per cent in the

third. The schizophrenics, however, are preponderantly in

their 30's: 34.1 per cent; the fourth category adds 15.7

per cent.

Roaert E. L. Fans and H. Warren Dunham, Mental Di s~ S l t e H M ^ i A r e a s , (Chicago, 1939), pp. 39, 64, and~244.

O T 3 i

Diagnostic Categories

In order to pursue this apparently parallel experience,

as discussed in the preceding paragraph, the distribution of

population by geographic birthplace has been controlled for

diagnosis (see Appendix F). This largest segment, the West

South Central group, is shown in Table VII in a percentage

distribution based on their total number {N=241) and broken

down by diagnostic categories. »

TABLE VII #

PERCENTAGE DISTRIBUTION OF POPULATION DERIVED FROM WEST SOUTH CENTRAL REGION

' BY DIAGNOSTIC CATEGORIES

Diagnostic Categories Per Cent

Schizophrenic reactions 52.7

Psychotic disorders other than

schizophrenia . . . . . . . . 16.6

Psychoneurotic disorders . . . . . . 14.$

Personality disorders „ 16.2

Total N=241 100.0

Comparison of the prevalence of one type of mental dis-

order to that of others receives little attention from ecolo-

gies; perhaps it is considered, sufficiently well-known that

schizophrenics far exceed any other 'disorder, and in fact

38

may often contribute the majority of cases in any particular

study. Hollingshead and Redlich state that, "In all classes

2

schizophrenia is the predominant psychotic disorder." ' In

their statistical corroboration of this statement, having

divided a population of 1451 patients into four social classes,

they show in each class 55, 5 7 } 61, and 5$ per cent of the

cases falling within- that class to be schizophrenic: con-

sistently a majority of cases in all classes. To discover,

then, that a majority of any specified group of mentally ill

persons are,suffering schizophrenic reactions is in keeping

with past experiences..

Age and Diagnostic Categories

The intention here, however, is to pursue the age distri-

bution within the geographic distribution of place of birth

and to control this distribution by diagnostic category.

Complete tables showing the breakdown controlled for each

diagnosis under examination in this paper are contained in

Appendix G. From these tables the West South Central segment

has been extracted from each table and presented In one com-

Dined table in order tc more readily contrast patterns of •

distribution.

.~August B. Hollingshead and Frederick C. Redlich, Social Class and Mental Illness, (New York, 1953), p. 228.

39

- TABLE VIII

PERCENTAGE DISTRIBUTION OF WEST SOUTH CENTRAL POPULATION, ACCORDING TO AGE BY DIAGNOSTIC CATEGORIES

Diagnostic Category 2 5 - 2 9 3 0 - 3 9 4 0 - 4 9 5 0 - 5 9 6 0 Total

Schizophrenic reactions . 7 3 . 3 5 B » 5 5 1 . 6 2 6 . 1 2 0 . 0 5 2 , 7

Psychotic disorders other than schizophrenia 4 . 3

*

4 . 7 1 4 . 7 5 0 . 0 6 0 . 0 1 6 . 6

#•

Psychoneurotic disorders 4 . 8 2 1 . 4 1 6 . 1 9 . 6 • » « » 1 4 . 5

Personality-disorders 1 6 . 6 0 1 5 . 4 1 7 . 6 1 4 . 3 2 0 . 0 1 6 . 2

Total N = 2 4 1 1 0 0 . 0 1 0 0 . 0 1 0 0 . 0 1 0 0 . 0 1 0 0 . 0 1 0 0 . 0

In this table (VIIJ.) the schizophrenic reactions are

plainly preponderant for the entire group and even more

remarkably so in the lower age categories as has been the

case in other research Into schizophrenia. A downward grad-

ient inverse to the age gradient is quite evident in the

area of schizophrenic reactions. However, the prevalence

of psychotic disorders other than schizophrenia increases .

rapidly with age. The other diagnostic categories in this

study do not demonstrate arty striking pattern of age-linkage:

40

psychoneurotic disorders increase in the two decades 30-50

in conjunction with a decrease in schizophrenic reactions

while personality disorders remain fairly stable (14-20 per

cent) in the age groups under study.

The percentage distribution of schizophrenic reactions

is in keeping with Faris and Dunham's findings in the Chicago

• q

area in reporting an age analysis of schizophrenic cases.

In their report they cite still other analyses as providing

further confirmation that "the bulk of schizophrenic cases

. . .fall in. the middle years of life."̂ However, as Eaton

and Weil note, symptoms of schizophrenia frequently have their 5

onset during late adolescence or the' early years of adulthood.

Spatial Mobility

These'data provide no evidence of extensive spatial

mobility among this population; Table V, Chapter II, presents

all the data available on the mobility of these patients.

This is in keeping with the experience of other research in

attempting to analyze mobility and its effects, If any, upon

3 • " ' Faris and Dunham, ojd. cit. , p. 40.

^Ibid., p. 40.

pJoseph. W. Eaton and Robert J..Weil, Culture and-Mental Disorders, (Glencoe, 1955), p. 107.

41

mental illness. Queen protests that the various ecological

studies differ so in the measures of mobility that ''they are

6 7

not strictly comparable." Dunham's 1946 paper deals, in

part, with the elusiveness of clearly defined evidences of

mobility in seeking further corroboration of his (and Faris')

refutation of the drift hypotheses.

The "drift" hypothesis or theory is simply an assertation

that the mentally ill or disordered person will likely become

an economic failure and will then drift into certain areas &

characterized by high rates of commitment to mental hospitals.'

This theory has been advanced by some psychiatrists as a pos-

sible explanation of the findings of Faris and Dunham in their

ecological study of the Chicago area.^ Faris and Dunham have

refuted this theory, both by investigation in depth of commit-

ments from these depressed areas and by pointing to their

^StUart A. Queen, "The Ecological Study of Mental Dis-orders," American Sociological Review, V, 1 (February, 1940), p. 205.•

7 H. Warren Dunham, "Current Status of Ecological Research

in Mental Disorders," Social Forces, XXV (March, 194?).

Holiingshead and Redlich, o£. cit., pp. 244-24$.

9 'Dunham, ojo. ~cit. , p. 323.

42

findings in regard to manic-depressives."*"^ Dunham points

out that some persons feel that the nature of the manic

reaction is such that many persons who develop this type

of disorder frequently establish themselves in high status

positions. But Dunham states himself that the drift theory

1 1

is primarily concerned with intra-city investigations,

which do not enter into this study.

Therefore, no attempt is being made here to evaluate

the drift theory in terms of these data. Specifically,

these other studies are more directly concerned with intra-

city mobility rather than inter-regional. Thus the lack

of.these data to present conclusive evidence of mobility

can in no way be interpreted as substantiating or refuting

drift" as an explanatory factor in mental disorder. ?T

Occupational Categories

In order to examine this West South Central segment of

the population in further depth, but in another frame of

reference, the population has been tabulated according to

geographic region of birth place and controlled for occupation

The complete percentage distribution of the population is

~°Ibid., p. 3 23 .

-^Ibid. , p. 323 .

43

presented, in Appendix' H; the extracted percentage distri-

bution of the West South Central segment among the occupa-

tional groups is shown in Table IX.

TABLE IX'. '

PERCENTAGE DISTRIBUTION OF WEST SOUTH CENTRAL SEGMENT OF THE POPULATION BY

OCCUPATIONAL GROUPINGS

Occupational Group , Per Cent

Professional 20.5

Farmers and .Farm Managers 7.$

Proprietors . . . . 21.3

Clerical . . . . . . . . . . . . . . . 20.1

Craftsmen 8.7

Operatives _5#g

Service Workers . . . . . . . . . . 1.6

Laborers . . . . . . . . . . . 2.4

Students . . . . . . . . . 1.6

No Occupation 4.5

Miscellaneous 3.7

Not Ascertainable . . . . 2.0

Total N=241 . . . 100.0

44

In Table IX, the white-collar occupational groupings,

professional, proprietors, and clerical account for 61.9

per cent of the distribution. In this study, this can only

be considered an indication of the composition of the hos-

pital's population and not an indication of any correlation

between social class and mental illness. This figure simply

indicates the predictable fact that a relatively expensive

hospital -will admit' a larger proportion of economically well-

situated persons, even in this day of widespread health

insurance coverage. Insurance, indeed, may account for the

clerical distribution being substantially equal to either

professional or the proprietors. Insurance, again, may

account for the 8,7 per cent of craftsmen and the 5.8 per

cent of operatives as opposed to insignificant percentages

among all other blue collar groups.

- The assumption that a distribution of cases heavily

weighted, toward the upper social classes is only a charac-

teristic of the extraordinary composition of the population

of this particular private hospital is supported by the

fact that ecological studies in general agree that mental

disorder rates are higher among the lower socio-economic

groups than among the higher. Dunham notes that:

_ The one point on which all of the ecological studies of mental disorder so fax are in agreement

45

Is the fact that ail types of mental disorder show a wide range of rat.es in thsir distribution and that the high rates are invariably concentrated in areas at the center of the city with the rates declining In magnitude toward the periphery."1"

Dunham also reported that he and Faris collected statis-

tics from private sanitariums in the Chicago area to combine

with their previously collected data from public hospitals

simply to refute any suggestion that the finding of greater

prevalence of mental disorder among the lower classes was

only a reflection of the class composition of the population

of public hospitals. He reports that these combined data

demonstrated a 15 times greater likelihood of mental hos-

pital commitment for the resident of the economically deprived

portiono of tne city unan for the residents of the more privi—

13 leg-ed areas.

More recently, Hollingshead and Redlich In their study

ot social status, and psychiatric illness confirm the exist-

ence o.t this inverse relationship between social class and

mental illness. They state:

(1) A. definite association exists between class position and being a psychiatric patient,

(2) The lower the class, the greater the pro-portion of patients in the population.^

.1̂ 1 bid.., p. 321.

13lbid., p. 323.

^Hollingshead and Redlich, o£. oift». p. 216,

46

Occupation arid Diagnostic Categories

In order to study nore clonely this West South Central

segment of the population, the entire population was con-

trolled for diagnostic category in addition to the breakdown

of geographic region of birth by occupation groups. The

tables derived from this operation are contained in Appendix

I, From these tables it was possible to extract the infor-

mation on the West South Central group in order to compare

relative rates of the various types of disorders among the

several occupational groups. This analysis is presented in

Table X.

Before attempting an analysis or interpretation of

these data examining the possibility of some relationship

between occupation, per se, and types of mental illness,

close attention should be directed to the introduction to

i 5 Frumpkin's article, "Occupation and Mental Disorder."

Here he states that "few studies have been done specif-

ically on the subject of occupation and mental illness."16

He continues with an argument supporting the close connection

1 7 oetween occupation and social class. The use of occupation

1?R. M. Frumpkin, "Occupation and Major Mental Disorders," i n Mental Health and Mental Disorder: A Sociological Approach,' edited by A. M. Rose, (New York, '1.555 ), pp. 136-160.

16 T "K -4 A ~l /I

47

TABLE I

PERCENTAGE DISTRIBUTION OF WEST SOUTH CENTRAL POPULATION EI OCCUPATION AND

DIAGNOSTIC CATEGORY

Diagnostic Category

Occupational Group

Schizo-phrenic Reactions

Psychotic Disorder Other than Schizo-phrenia

Psycho-neurotic Disorder

Personal-ity Disorder

Professional 16.8 . 20.0 28.5 25.8

Farmers and Farm Managers 7.0 10.0 2.8 12.8

Proprietors 18.4 12.5 31.8 30.9

Clerical 18.9 27.5 20.0 15.3"

Craftsmen 11.0 7.5 5.7 5.1

Operatives 6.2 12.5 » * » • 2.5

Service ; Workers 2.3 # $ • * 2.8 e * « «

Laborers 2.3 7.5 9 3 « » * • • •

Students

1—1 • cn 9 * » « * * * • « * « 9

No Occupation 6.2 * * * # 2.8 5.1

Miscellaneous 4.7 2.5 2.8 2.5

Not Ascer-tainable •3.1- • #• * # ' "2.8 • • * *

Total N=241 100.0 100,0 - 100.0 100.0

43

as a pertinent index of social class has been discussed in

Chapter I. However, social class and occupation are not

precisely identical; other factors than occupation enter

into any complete and comprehensive determination of an

individual's social class. Therefore it is possible that

these data, based solely upon occupation, may produce findings

not strictly comparable with other studies of social class

and mental illness. However, Hortwitz and Smith have found

more commonly used indicators of class to be highly corre-

18

lated, both individually and in combination.

In any event, this study only intends to describe the

characteristics of the studied, population and does not pre-

tend to perfectly replicate older studies, nor to advance

new hypotheses or theories. The psychoses described in this

study are the functional psychoses. This study will describe

the characteristics of prevalence in this particular private,

psychiatric hospital, and it is anticipated that some charac-

teristics will emerge which will not correspond with the

findings of earlier, more comprehensive studies, largely

emphasizing public hospital populations.

If* Hortehse Hortwit3 and Elias Smith, "The 'Interchange-

ability of Socio-Economic Indices," The Language of Social. Research, edited by Paul F. Lazarsfeld and Morris Rosenburg. (New York, 1955), pp. 73-77.

49

In each diagnostic category, as shown in Table X, the

professional, proprietors, and clerical groups in combi-

nation outweigh all other groups. But there are discernable

differences: This white collar combination accounts for

54-1 pe** cent of the schisophrenics, 60.0 per cent of other

psychotic disorders, $0.3 per cent of the psychoneurotic

disorders, and 72.0 per cent of the personality disorders.

Schizophrenic reactions are more nearly equally distributed

among white collar and non-white collar groups than any of

the other diagnostic categories, whereas the non-schizo-

phrenic diagnoses show a discernable bias toward these

socially advantaged groups.

At first glance these findings may seem to run contrary

to the findings of other studies, for it is generally agreed

that, as stated by Frumpkin, "there is a group differential

in the rates of first admissions which is inversely related

to the factors of income, prestige, and socio-economic status

as these factors are manifested in o c c u p a t i o n . " " ^

However, it must be remembered that this is an extremely

limited study and that the lower social-economic classes are

woefully underrepresented in-the population under examination.

Rather than place undue emphasis upon the totals of these

>0

white collar gro.,_: a.: .'-.fast C tc t^c ::maJler totals of

non-white collar ;-tie:v::, . ;;t-- ~.-on be directed to

the differences amorg the v,-hite collar groups themselves.

There is but scant difference in the percentages of

the three white collar groups within the schizophrenic

reaction category: Professional, 1 6 . 3 per cent; Proprietors,

16.4 per cent; and Clerical. 1S.9 per cent. Nevertheless,

even these small differences do follow Hollingshead and

Redlich's demonstration of an inverse relationship between

class status and prevalence of schizophrenia.2^

A somewhat different picture emerges for the disorders

other than schizophrenic reactions. The "psychotic dis-

orders other than =chizoprrenic" category, principally

manic-depressives, shows 27.5 per cent of its total to be

in trie clerical gionp, exceeding both the 20.0 per cent for

professionals, and the 12,5 per cent for proprietors. In

this category? the proprietors are matched equally by the

operatives, also showing 12.5 per cent. This pattern immed-

iately brings to mind the remark by Hollingshead and Rsdlich,

at the conclusion of their chapter, "Class Position and Types

of Pent?! Illness: n 'fThe problem of interpretation cf these

O i .lIc ilirî chear1 and Pedlich, od, cit., d , 236.

51

differences remains."'""1" The sociologists have generally

come to accept the manic-depressive diagnoses as more

prevalent among the upper classes, as indication of a more

advantaged social and financial position in the community.

And yet here we see the clerical group exceeding any other,

and the craftsmen equal in prevalence to the proprietors.

This particular finding, the equal percentage of the

proprietor group and the operatives is analogous, however,

to the finding by Hollingshead and Iiedlich in the same par-

ticular case. The proprietor group in the present study can

be related to their Class III and the operatives group

studied here would most closely correspond to their Class

IV. They too found an equal percentage of cases of affective

22

psy'chotics in Class. Ill and Class IV.

What are the factors that contribute to this heavy

over-contribution of the clerical group to the non-schizc-

phrenic diagnoses? The answer is not to be found In reference

to other, past studies. A tentative explanation of this

interesting finding is offered below; the data .required for

further investigation are not available.

21Ibid., p. 249.

2~Ibid., p. 228.

52

Reference to the list of actual occupations contained

in the clerical groups shows these to be the very people

who suffered hardship resulting from an affluent society.

These are the "men between": between the professionals and

the proprietors, on the one hand, who can ride the,crest of

a 'wave of affluence protected by increasing fees and emolu-

ments at their own. direction and, on the other hand, the

-tradesmen, operatives3 and craftsmen who are carried along

by such a wave, protected by union contracts, minimum wage

laws and all the machinery that extends the benefits of a .

Great Society to the working classes.

Meanwhile, the -clerical group,- the "men between-,"- "

bears the burden of supporting this machinery, These are

the true representatives of the middle class—the class

driven- to -ever-greater accomplishments—the class dedicated

to ever-greater aspirations, truly dedicated to "keeping up

with the Jones'" but poorly equipped for the task. They

attempt to use deferred gratification, implemented by a

secure credit rating, as a tool. They must try to use this

tool to wedge a place for themselves in this new, affluent

world. The little place, they wedge for .themselves—a mort-

gaged home in the suburbs, a respectable, "clean" job, an

automobile that is never paid for, and a pair of children

53

progressing through "better" schools, but eventually destined

to enroll in a non-prestige college—all of their little

place in the xirorld is subject to constant threat of annihi-

lation. But not' only is this little world threatened with

extinction-in-thirty-days~when-the-note-comes-due, but this

group is constantly exposed to the frustration of semi-

participant observation of the world of the proprietors,'the

managers and the professionals. This is the world to which

the clerks aspire--i.f not for themselves, then at least for

their children—this is a world which appears serene and

untroubled to the financially frustrated, middle-class clerk.-

•His own existence hangs by the thread of employment, an em-

ployment wholly without tenure in most cases; the thread

becomes increasingly fragile with each advancing year.

Metropolitan Status and Size

As discussed earlier, the size of the city along with

the characteristics customarily associated with size—degree

of heterogeneity of values, goals, customs, ethnic backgrounds--

has been founc to be related to extent of treated mental disorder 23

^3Paris and Dunham, ojd. ext., pp. xi-xvii. Also, Albert J. -Rei-ss, Jr., "Functional Specialization of Cities," in Cities and Society, Revised Edition, Paul K. Hatt and Albert J. ReissT Jr., as editors,..(Flencoe, 2957),. pp. 560-561, and William Fielding Ogburn and Otis Dudley Duncan, "City Size- as a Socio-logical Variable," in "Contributions to Urban Sociological Variables," in Contributions to Urban Sociology, Ernest W. Burgess and Donald J, PcgueT editors," "(Chicago7 1964). pp. 129-147.

54

and may be related to type of disorder as well. Detailed

examination of variations in city size by age group, diag-

nostic category and occupational grouping will show the

effects of this particular data.

A review of terminology seems appropriate. Metropolitan

includes those cities with a population in excess of 50,000,

whether located in a standard metropolitan statistical area

or not. Ring cities are those with a population between

2,500 and 50,000, but located within the limits of a standard

metropolitan statistical area. Independent cities also have

a population between 2,500 and 50.000, but are presumed ecolog-

ically independent of some major or central. city. In prac-

tice, this means that they are not located within a standard

metropolitan statistical area. Rural includes places, incor-

porated or not, with a population of 2,500 or fewer persons.

Table III (Chapter II, p. 28) gives the percentage distri-

butions of patients' residences by city size: metropolitan,

50.5 per cent; ring cities, 16.1 per cent; independent, lg.6

per cent; rural, 5»4 per cent; not ascertained, 9.4 per cent.

In examining ecological size of city (see Table XI), by

age groups, 47 per cent or more of each age group (excluding,

the age 60 group) reside in metropolitan cities; when metro-

politan and ring cities are combined, this increases to 60

55

per cent. In examining age of patients and size of their

city of residence, persons over 60 deviate from an otherwise

relatively uniform pattern. Fifty per cent of those 60 and

over resided in independent cities.

TABLE XI

PERCENTAGE DISTRIBUTION QF POPULATION BASED ON METROPOLITAN STATUS

AND SIZE BY AGE

Metropolitan . Age . _ Status and Size 25-29 30-39 40-49 50-59 60

Metropolitan 47«4 50.4 - .54.9 49.2 . 33.3

Ring - 27.-3 19.1 11.8 .11.2 e «> • m

Independent 15.6 19.3 14.7 19.1 50,1

Rural 1.9 3.3 8.3 6.3 3.3

Not Ascertainable 7.8 7.4 9.8 14 • 1 8.3.

Total N-349 100,0 100.0 100.0 100.0 100.0

Similarly, in examining metropolitan status, age, and

psychiatric diagnoses (see Table III), a preponderance of'

cases within each diagnostic category is to bo found in

metropolitan cities; when their ring cities are combined

with them, the urban character of the patient population is

even more striking. One irregularity deserves comment: a

5 6

noticeably larger percentage of patients diagnosed as

psychoneurotic resided in metropolitan areas.

TABLE H I

PERCENTAGE DISTRIBUTION OF POPULATION BASED ON METROPOLITAN STATUS

AND SIZE AND DIAGNOSIS ,

Metropolitan Status and Size

Psychotic Disorders (other than Schizophre-nic )

Schizophre-nic Reactions

Psycho-neurotic Disorders

Personal-ity Dis-orders

Metropolitan 4 3 . 3 4 8 . 6 6 3 . 4 4 5 . 7

Ring 6 . 9 2 1 . g ' 1 2 . 9 1 0 . 5

Independent 2 0 . 7 I d . 9 1 2 . 9 2 1 . 0

Rural 1 0 , 4 3 . 4 5 . 4 7 . 0

Not ascer-tainable 1 3 . 7 7 . 3 j . 4 1 5 . 8

Total N = 3 4 9 1 0 0 . 0 1 0 0 . 0 . 1 0 0 . 0 1 0 0 . 0

In examining metropolitan status and sn ze with diagnosis

and age held constant, the small number of cases reduces the

meaningfulness of comment outside the diagnostic category of

schizophrenic reaction. There are fewer than 60 cases in

each of the diagnostic categories, excepting schizophrenic

reactions where N=179. (See Appendix F).

57

In Table XIII, there appears tc be some relationship

between youth and residence in the ring in the development

of schizophrenic reactions: note the relatively high fre-

quency of the 25 to 29 group in the ring cities (30.7 per

cent), as opposed to moderate frequencies in the other age

groups. Otherwise, the urbanicity-age distribution rather

closely parallels the total age distribution of this popu-

lation. The concentration of rural patients in the 30 to

«

49 year group is also interesting.

TABLE XIII

PERCENTAGE DISTRIBUTION OF THE SCHIZOPHRENIC CATEGORY BY METROPOLITAN STATUS

AND SIZE AND AGE

Age Metro-politan

Ring Indepen-dent

Rural Not Ascer-tainable

Age Dis-tributioi

25-29 19.5 30.7 17.8 s • # # 15.4 17.4

30-39 41.3 35.3 4.4.1 50,0 33.4 34.8

40-49 31.0 23.3 26.4 50.0 23 .1 28.3

50-59 6.9 10.2 3.(3 * 0 • • 23 .1 17.4

60 1.3 • • • » 2.9 * 9 9 » • • « • 2.1 '

Total N=179 • 100.0 100.0 100.0 100.0 100.0 100.0

53

When metropolitan size and status .is controlled for

occupation in Table XIV, -predictable distribution of occu-

pation appears within each metropolitan status: Proprietors

are more common 'in independent cities, clerical occupations

in ring as well as in metropolitan cities. However the most

TABLE XIV

PERCENTAGE DISTRIBUTION OF POPULATION BY METROPOLITAN SIZE AND STATUS

AND OCCUPATION

Occupation Metro-politan

Ring Inde-pendent

Rural Not As-certain-able

Professional 2 0 . 3 1 7 . 8 1 6 . 9 2 6 . 3 2 1 . 2

Farmers and farm managers 2 . 2 1 . 9 1 5 . 1 3 6 . 8 6 . 3

Proprietors 1 9 . 1 -• 1 6 . 1 . 3 1 . 2 1 0 a 4 3 8 . 2

Clerical 3 0 . 6 2 5 . 6 6 . 2 • * ® « 2 1 . 2

Craftsmen 7 . 0 1 3 . 6 1 2 . 3 5 . 3 3 . 4

Operatives 3 . 3 • 3 . 6 6 . 2 . 5 . 3 e • * •

Service Workers 1 . 6 . 3 . 6 » • • * • # • • * • « *

Laborers 1 . 6 6 . 8 1 . 5 5 . 3 e # # #

Students l.-i 1 . 9 1 . 5 # ~ » * 6 . 3

None 6 . 7 3 . 6 1 . 5 5 . 3 3 . 4

Miscellaneous 4 . 4 3 . 6 . 6 » • • • e # • •

Not Ascertainable 1 . 6 1 . 9 3 . 0 5 . 3 9 • *

59

cursory examination of Table XIV reveals the dispropor-

tionately high percentages of v/bite-coilar workers and

particularly professionals in almost every metropolitan

status grouping.. Thus, the contents of Table XIV directly

reflect the essentially white-collar nature of the sani-

tarium's patient population. As discussed earlier, the

sanitarium's per. diem cost prohibits wider use by persons

in the lower soeio-ec.onomic groups.

In analyzing metropolitan status and size, controlling

for diagnosis in addition to occupational group, the same

limitations in terms of cell frequency exist as described

with reference to the factors treated within Table XIII.

Therefore, an elaborated form of these tables appears in

Appendix J, Table XV, which follows, is a collapsed version

of the same data. For the purpose of this tabulation, the

expression "white collar" includes the discretionary cate-

gories, namely professional, farmer's and farm managers, and

proprietors; the clerical category, owing to its relatively

large size, has not been collapsed; the categories of crafts-

men, operatives, service 'workers, and laborers have been

combined under the heading "blue collar," and the remaining

groups (students, none, miscellaneous, and not ascertainable)

have bean categorized simply as "all others." The patients

60

whose metropolitan status was not

included in Table XV.

-tainable were not

TABLE XV

PERCENTAGE DISTRIBUTIONS BY OCCUPATIONAL GROUPINGS ACCORDING TO METROPOLITAN STATUS AMD SIZE

BY DIAGNOSTIC CATEGORIES

SCHIZOPHRENIC DISORDERS

Occupational Group

Metro-politan.

Ring Inde-pendent

Rural Occupa-tional Distri-bution

White Collar Clerical Blue Collar All Others

44«4 22.6 15.4 17.6

30.3 20.5 33.3 15.4

. 53.3 11.7 17.3 11.7

33-3 e * # e

33.3 33.4

41.2 20.7 20.7 17.4

Total N-179 100.0 100.0

PSYCHOTIC DISORDERS OTHER T;

100.0 100.0 100.0

4AN SCHIZOPHRENIA White Collar Clerical Blue Collar All Others

35.7 . 46.5 17.3 • « # •

50.0 25.0 25.0 # « * m

45.4 : * 9 * *

45.4 9.2

30.0 • • * #

20.0 • • • •

46.6 29.3 22.4 1.7

Total N=5o 100.0 100.0 100.0 100.0 100.0

. . PSYCHONEUROTIC DISORDERS

White Collar Clerical Blue Collar All Others

54.5 23.5 8.5 3,5

57.1 42,9 • e » * * # 0

33.3 • * » *

16.7 * * » •

100.0 e • « *

D> • •® • «* • * »

60.0 25.4 7.3 7.3

Total N=55 100.0 100.0 100,0 100.0 100.0 r

PERSONALITY' DISORDERS

White Collar Clerical Blue Collar All Others

33.5 34.6 11.5 15.4

33.3 33.3 33.4 • * a a

91.7 • « * #

* * • • 3.3

100.0 : « « * c<

# « &

61.4 19-3

& O * 0 10.5

Total N=57 100.0 100.0 100.0 100.0 100.0

61

The results of examination z>f the data upon which Table

XV is based rather directly reflect occupational distribution

as related to metropolitan status; however, the preponderance

of schizophrenic, white-collar males, in terms of numbers in

this sample would render sweeping generalizations questionable

However, Table XV reveals several interesting character-

istics of this population. First, despite the predominance

of white collar and clerical workers in this population,

Table XV bears out, in a most general way, the findings by

Hollingshead and Redlich in New Haven. "The external tests

show that when the neurotic disorders are grouped together,

a direct relationship appears between class status and the

extent of treated neuroses in the population. The reverse

24

is true for the psychotic disorders."

A second finding is that in rural and independent

statuses the white collar occupations contribute virtually

all neurotic disorders. This in contrast to the ring and

metropolitan statuses where lower occupational groupings

show at least some representation in the neurotic disorders.

Given their gross underrepresentation in this population

this seems to be significant in a social, though not statis-

tical, sense.

p j """"Hollingshead and Redlich, 0£, cit., p. 240.

62.

If this is5 in fact, socially significant, the greater

representation of .Lower level O'jcupatioiicLi. groupings .in the

more urban environments may reflect a greater acceptance of

neurosis as a mental illness, and more affluence in the urban

areas in spite of occupational level or even a larger number

of persons suffering neuroses as a result of the urban "rat

race." These data can not, however,- explain this finding.

Finally, while'occupational grouping is known to be and

is also in this case related to type of illness, metropolitan

status in conjunction with occupational grouping appears to

provide the basis of a still stronger predictive device. In

Table XV, examination of the distribution of cases on each

side of a diagonal which places metropolitan status above

and rural status beneath the diagonal reveals a consistent

decrease in representation beneath the diagonal. In other

words, probability of treatment (in this sanitarium) decreases

directly with both occupational grouping and size or metro-

politan status.

Zones of Residence

In order to examine the geographical pattern of distri-

bution of functional disorder within the area served by the

hospital, as discussed in Chapter I, arbitrary zones were

established, ks shown in Table XVI, fewer than ten per cent

63

of the patients in the population reside outside of Texas,

For this reason the analysis of ^onal variation has been

confined to zones established within the Texas borders, as

shown in Figure I.

Studying Table XVI, in terms of the established zones,

it will be seen bhat nearly 47 per cent of the population

resides within Dallas County; 35 per cent, in fact, live

within the city's limits. An additional 19 per cent live

within 100 miles of the sanitarium; only eleven per cent live

300 miles or more from the sanitarium.

In controlling for age, patients between 30 and 49

years of age are more likely to be from Dallas (city) proper,

than are the younger and older age groups; the group least

likely to be from Dallas city and county, are those 60 years

of age, followed by the 50 'co 59 year old group. This could

be the result of increased tolerance of deviant behavior

among older persons, especially in urban settings (see Table

XVI). It is widely accepted that eccentric behavior among

older people results from senility, and in addition, the

heterogeneity characteristic of contemporary urban settings

is productive of greater tolerance of mild deviance.

When diagnosis is controlled, schizophrenic inactions

a.nd psychoneurotic disorders are more common, within fifty

64

I. Under. 50 miles

.II, 50-100 miles

III, 101-200 miles

IV. 201-300 miles

V. 301 miles and beyond

O s o iOO

SC.UE

65

miles of the sanitarium than are psychotic disorders

(other than schizophrenia) and personality disorders,

TABLE XVI

PERCENTAGE DISTRIBUTION OF POPULATION BASED • ON ZONE OF RESIDENCE BY AGE GROUPS

No. Zone of Residence 25-29 30-39 40-49• 50-59- 60 Total

1. Dallas 29.9 33,3 33.6 30.5 25.2 35.2

^ * Dallas Co. 19.6 14.5 7.3 7.9 * a t « . 1 1 . 4

3. Under 50 mi. 15.6 9.0 9.3 11.1 16.6 20.3

'+ * 50-100 mi. 5*3 6.6 6.3 11.1 25.0 3.0

5. 101-200 mi. 5.3 7.4 10.7 12.6 16.6 9.4

6.. 201.-300 mi, 5.3 3.3 4.9 3.1 3.3 4.2

7. 301 mi. plus 11.7 12.3 10.7 9.5 * • • • 10.3

3. Contiguous states 5.3 5.7 3.3 1 1 . 1 3.3 7.7

9. Non-contig-uous states 9 « • C 1.6 1.9 3 . 1 w • « • ' . 1 . 7

10. Not Ascer-tainable * # « a 0.3 * * « # * • » to * c e # 0.2

Total j 100,0 100.0. 100.0 100.0 100.0 100.0

Table XVII, which follows, gives the percentage distri-

bution of the studied population in terms of zones of residence

66

and diagnostic categories. Examination of this table reveals

that residents of the Dallas vicinity (less than 100 miles

from the city of Dallas) are more likely to be admitted for

TABLE. XVII

PERCENTAGE DISTRIBUTION OF POPULATION BASED ON ZONE OF RESIDENCE AND DIAGNOSTIC CATEGORIES

No. Zone of Residence

*

Schizo-phrenic Reactions

Psychotic Disorders (.other than . Schizo-phrenic

Psycho-neurotic Disorders

Person-ality Dis-orders

i - i - •

Dallas 36.8 34.9 40.3 23.4