y Montes-Yedra Jacobo 2

Mid-Range Group

We now discuss the decompensated states that we have seen in asso-ciation with mid-range soft and decrement profiles. These profiles consist of eye-rolls in the 2–3 range and either zero levitation and a

positive control differential, which is a soft pattern, or zero control differential, which is a decrement pattern.

Sociopathies

People with sociopathic disorders are highly active. Their emphasis is on manipulation and action rather than on feeling, and their affect is commonly described as shallow, rather than overwhelming, as with bipolar disorder patients, or flat, as with schizophrenic patients.

Patients with sociopathy tend to be suspicious of others and are well known for resistance to compliance with external signals. They are more inclined to busily engage in getting other people to comply with their purposes than to be at all receptive toward accepting input from others about their behavior. Their compulsive rationalizing of their feelings and behavior often serves to justify the behavior after the fact, frequently in a somewhat paranoid fashion. Many people with sociopathies have clear paranoid features; underneath their manipu-lative hyperactivity is a delusional, paranoid core. Action is what counts for these individuals, and they often respond best to a highly structured and disciplined therapeutic approach.

Characteristic of their position, which is near the Odyssean group, they are often described as being pseudonormal. Havens^* has de-scribed the patient with sociopathy as someone who gives an inter-viewer the feeling that he, the patient, is more normal than the interviewer. Patients with sociopathy create an impression of normalcy that is useful to them, yet they are compelled to act in such a way as to avoid any real feelings. It is in this area that we believe many of the patients described as borderline by Grinker et al. (1968), Kern-berg (1975), and others belong. We expect in borderline patients with decrement profiles such characteristics as micropsychotic epi-sodes; the tendency to project and manipulate, to split objects in their world into good and bad categories, and to fear abandonment; shal-low affect; and a strong tendency to act rather than feel. However, they may be hard to distinguish from those patients diagnosed with sociopathy or with paranoid character disorders. We thus see them as being decompensated Apollonians or Odysseans with paranoid and sociopathic features, as in the following example.

*Havens, L.L., personal communication, 1970.

K.U. was a 23-year-old, separated father of three. He was seen for psychiatric evaluation after his arrest on charges of rape and murder. The crime was a particularly brutal one, and the defense argued that he had a “dual personality” and was therefore psychotic during the crime. His parents were divorced when he was an infant, and his mother’s remarriage was marked by repeated separations. He completed high school, had no prior criminal record, and had worked as a laborer before his arrest.

The HIP was administered, and he scored a 2–3 soft pattern with an induction score of 5. The survey of cluster characteris-tics yielded mixed features. Formal psychological testing re-vealed the following information:

“K.U.’s test results indicate poor identity formation, character-ized by marked feelings of inadequacy, inferiority, schizoid ten-dencies, depression, and depersonalization. Feelings of loneliness and emptiness pervade the test responses, suggesting a borderline personality disorder. If stressed too far where tolerance for ego deflation has reached an impasse, a sharp lack of impulse control may definitely reflect his (lack of) ability to cope adequately with the stress-inducing situation. His borderline structure is primarily a developmental defect, in which a fundamental deformity or in-adequacy of ego-functioning prevails.”

In short, K.U. was found by the court to be characterologi-cally impaired, but not histrionic, psychotic, or legally insane.

The psychological test results and the initial impression generat-ed by the profile score were consistent with the diagnosis of a person with borderline sociopathy. Without a high-intact pro-file score, hysterical dissociation or so-called dual personality was unlikely. On the other hand, one would expect to see a 1 or 2 decrement profile if the subject had schizophrenia. The 2–

3 soft pattern was a statement of K.U.’s marginal psychologi-cal functioning with poor impulse control. He was not so im-paired that the ribbon of concentration was entirely disrupted, but his trance capacity was hardly so profound that it could be invoked to explain the postulated dissociative episodes. The court found him to be sane and guilty.

It is our experience that the HIP has been useful in making the dif-ficult distinction between borderline schizophrenia and primary hys-teria; patients with the latter have high-intact profiles, and patients

with the former often have soft or decrement profiles. This difference in the pattern of performance when hypnotizability is tested may be a reflection of a critical clinical distinction. Dissociative disorder pa-tients may have serious loss of function, exhibit psychotic symptoms, and be quite manipulative, but the underlying conflicts are usually of a positive libidinal nature. One establishes rapport easily with them, and they tend to be, if anything, too trusting and dependent in ther-apy. Thus, their willingness to “go along” with the hypnotic protocol is not surprising. Patients with genuine borderline disorders, on the other hand, tend to be somewhat hostile and paranoid. Coping with hostility and negative transference is the major work in psychotherapy with them (Kernberg 1975). Thus, it is hardly surprising that as a group they tend not to allow themselves to experience sensorimotor changes characteristic of the trance state. Their underlying hostility and suspicion interfere. The implications of this distinction for ap-propriate psychotherapies are further discussed in Chapter 18, Spec-trum of Therapies.

Impulse Disorders

Individuals with impulse disorders include those whose tendency to act rather than feel is similar to the tendency seen in patients with sociopathies, but the trait is less rigid and bound in hostility. This group includes individuals with a specific impulse problem in one but not all areas of their lives, such as some addictions or compulsive gambling. They may be more prone to soft rather than decrement profiles, are often more functional in other areas of their lives, and are less paranoid and suspicious than patients with sociopathies. It is not hard to see how a patient’s paranoid stance with regard to the world would interfere with his or her ability to experience many somatic sensory alterations at the request of another person.

Reactive Depressions

Patients with reactive depressions make up a group consisting of many fundamentally intact individuals who experience a relatively severe depression in response to a life stress. For a period of time, they may become immobilized, with decreased energy, interest, and involvement with others. At such times, their profile may become

soft. We have some clinical data to suggest that after recovery from the depressive episode, the intact mid-range trance capacity is re-established in these patients. As noted earlier, members of the Odys-sean group are prone to periods of depression between periods of activity. This group of patients with reactive depressions constitutes a fraction of the normal neurotic group whose depression becomes serious and immobilizing.

Passive-Aggressive Disorders

Patients with passive-aggressive disorders include individuals with characterological passive-aggressive traits, not merely those with such patterns in isolated neurotic form. Their relationships tend to be permeated with a quiet hostility, and they use their inaction in a cal-culated and manipulative fashion. At the same time, they often feel quite empty, lonely, and mistreated. They generally have soft or dec-rement profiles.

As a rule, these members of the soft and decrement group have a rel-atively fixed and inflexible pattern of responding, exemplified by a rigid and distorted compulsive triad (see Chapter 5, The Person With the Problem: Apollonians, Odysseans, and Dionysians). Patients with passive-aggressive disorders tend to distrust and fail to respond to new input, either ignoring or transforming it so thoroughly that it becomes virtually unrecognizable. They compulsively comply with an internally generated theme much more than to any external input; they are not open to outside direction and change. Furthermore, they are often densely unaware of the determinants of their compulsive activity; their reason serves not to illuminate but to justify their compulsive patterns of behavior. They have in common a poor hypnotic performance and are unresponsive to hypnotic signals, relative to their rather rigid adher-ence to their internally generated preoccupations.

Summary

The reflections included in this chapter are an attempt to assimilate a vast body of psychiatric data. The primary point is that the style of hypnotizability seems to be correlated with a large number of other

personal traits and problems: What is tapped in the trance state may broadly transform the individual’s world view of him- or herself, and his or her capacity and willingness to learn and act, into a brief and measurable behavioral performance.

The association between patterns of performance on the HIP and various clusters of character style and psychiatric disorders is pre-sented with some supporting evidence but is hardly an absolute or final picture. Rather, it is hoped that organizing the spectrum of per-sonality styles and psychiatric disorders in this way will prove clini-cally useful in thinking through differential diagnosis with the help of a brief assessment of hypnotizability. We have enough data to assert that the presence of intact-high hypnotizability should arouse the cli-nician’s index of suspicion that the patient is reasonably functional and has an intact, usable capacity to concentrate but may be vulnera-ble under stress to ASD and PTSD, dissociative disorders, or conver-sion disorders. In contrast, we have data to suggest that the presence of a soft or decrement performance on the HIP is consistent with se-rious psychopathology of different types, including schizophrenia and major depression. However, no such statistical association is ab-solute in an individual case. Such associations are best used to sharpen and refine a clinician’s diagnostic impression based on standard inter-vention techniques, including history and mental status examination.

It is hoped that the HIP will prove useful enough to be incorporated as part of the mental status examination of the patient. A patient’s inability to be hypnotized can be as clinically useful as entry into a profound trance state when evaluated in the context of structured hypnotizability testing.

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Neurophysiology of