LETTERS

framing

treatment,

expertise. important must

is the psychiatrist’s article is a valuable fruitful avenues

which

In sum, the and potentially

be

read

very

unique area of review of highly

of research,

but it

critically.

article

(including

our

syndromes is achieved only

REFERENCES

objectivity,

N. MA5sIE, Francisco,

HENRY

San

Drs.

Ornitz

and

Ritvo

N J

M.D. Calif

Reply

SIR: We heartily agree that a critical reading should be given to any review. This is particularly true of a ‘ ‘critical review,’ ‘ wherein authors may all too easily not only exercise their scientific judgments but also espouse their prejudices. We also appreciate Dr. Massie’s calling our attention to the fact that we had not been explicit enough in labeling one ofour chief “working hypotheses” as such. Thus, Dr. Massie formed the opinion that our ‘ ‘foremost unwarranted assumption’ ‘ is that autism’s symptoms are expressive of an underlying neuropathophysiologic process. Apparently we did not sufficiently emphasize that this was simply a working hypothesis,

to

not

our

assertion.

For

quote

our article, with state of our medical art leads (p. 618), and

the

record,

we

emphasis added: us to the following

‘

would

like

‘The current conclusion”

1 shows

the

nological

interrelationships

haviorally

defined

and

may

with

etiological

among

ego

that ofa

occur

on

specific

and

an

idiopathic

of

and

phenome-

clinically

and

primary

known

of

be-

cognitive

The

future

also

like to comment

on Dr.

Massie’s

opinion

Dr.

Massie

commented ism.

We

noted

that

on a similar were

ered the cited which although

aware

we did study

of

references heuristically

Dr.

Massie’s

as

not

regarding

review

his study

hypopituitary work,

but

and dwarf-

we

consid-

case reports or pilot projects, valuable were not cited in our

syndromes

etiology

such

conducting

as

of

understanding and emotional experi-

Determination

of the

autism

holds

the

answers.

Hopefully,

will

eti-

not

humanistic

be

Los

Organic

Brain

Dysfunction

and

like to question the M.D. . in “Personality

Dysfunction”

(July

M.D. Calif.

Disorder

conclusions

1976 issue).

M.D.

Angeles,

Personality

zeal

investigapatients

M. ORNITZ, R. RITv0,

EDWARD

reached

by

Disorder and Parietal Dr. Horton attempts

to reason by analogy between phenomena unquestionably characteristic ofpanietal lobe dysfunction and phenomena he alleges to be characteristic of personality disorder. The ‘ ‘hypothesis’ ‘ he reaches by this reasoning is that there exists a ‘ ‘relationship between personality disorder and nondominant parietal dysfunction. ‘ ‘ I would suggest that the phenomena alleged to be part of personality disorder are not present and that, consequently. Dr. Horton’s analogies break down, leaving his hypothesis without support. His

would

and

validity.

EDWARD

first

acteristic

We

the

and faithful adherence to the principles ofscientific tion will provide therapies to help our unfortunate and their equally unfortunate families.

CNS.

that we inadequately discussed the “potentional explanatory power of the intrapsychic experience of autistic children for some of the behavioral symptoms. ‘ ‘ This was done purposely. As stated in our conclusions, ‘ ‘we have tried to survey those studies which were based upon serious scientific efforts and avoid those which simply expressed opinions’ ‘ (p. 618). No one is more distressed than we (having both devoted many years to psychoanalytic training and to the treatment of psychotic children by psychodynamically based psychotherapy) that theories of intrapsychic and interpsychic experiences of autistic children remain in the realm of opinion. Unfortunately, they have not led, to our knowledge, to operationally defined hypotheses that have been tested by generally accepted scientific methods.

or our readers to between “organ-

regarding

‘

hypotheses,

complex

SIR: I would Paul C. Horton,

psychologically induced This model is based on of autism results from This neuropathophysiolbasis or in conjunction etiology that affect the

pathology).

the syndrome specific type.

diseases

the

ofautism,

retardation,

(severe

the hypothesis CNS pathology ogy

possible

syndromes

intellectual

psychoses

projects).

our students, controversies

their

EDITOR

reached by a single experiment, a series of experiments in one area, or, least of all, by opinionated debates. The answers will come only from diligent scientific investigations from varied perspectives accumulating evidence that stands the test of time, both by replication and by clinical experience. We say “answers” because, when we speak of autism, we must bear in mind that we are dealing with a behaviorally defined syndrome that clinical experience indicates can accompany (or be correlated with) many events. That such events may or may not be etiologic is a point on which we certainly agree with Dr. Massie.

Lobe Figure

to determine

ologies

THE

such as autism. Scientific by maintaining intellectual

establishing

ments

Powell GF, Brasel JA, Blizzard RM: Emotional deprivation and growth retardation simulating idiopathic hypopituitarism. EngI J Med 276:1271-1278, 1967 Massie HN: The early natural history ofchildhood psychosis. Am Acad Child Psychiatry 14:683-707. 1975

2.

pilot

‘

complex

I.

own

We do not wish ourselves, be polarized into obfuscatory icists” and ‘psychogeneticists’

TO

ty

of

analogy

of parietal patients

with

is

between

lobe

constructional

dysfunction,

personality

and

disorders

apraxia,

char-

an alleged to ‘ ‘relate

inabilitransi-

tionally. ‘ ‘ He goes on to intimate that the ability to relate transitionally consists of two parts: the ability to experience a phenomenon as ‘ ‘ soothing. ‘ ‘ and the ability to ‘ ‘ personalize and make an external object such as a blanket or a teddy bear internally meaningful. ‘ ‘ Clearly. as the author does not state that patients with parietal lobe dysfunction have an inability to be soothed, the proposed analogy here must be to the inability to personalize (except, perhaps, in those with borderline personality disorder). Such patients often have quite stable mental representations, which readily undergo projection, leading in turn to personalization ofexternal phenomena. Unfortunately for these patients, however, their mental representations are often felt to be unloving and/or cruel, and thus “personalized” phenomena are perceived as fearful, not soothing. Although I believe that the inability to

be soothed think that

is characteristic of personality disorder, I do not the alleged inability to ‘personalize” is present in ‘

personality

The

disorder;

second Am

analogy J Psychiatry

thus,

this

is between /33:12,

analogy

breaks

down.

the anosognosia December

/976

character1469

LETTERS

TO

THE

EDITOR

istic of parietal lobe ofillness in personality

to psychological

dysfunction disorder,

and a ‘ ‘lack of awareness” which is allegedly unrelated and ‘ ‘rigidly’ ‘ resistant to ‘ ‘vigorous approaches. ‘ ‘ I agree that padisorder lack awareness, but I do

conflict

conventional tients with

psychological personality

not believe

that

such

a deficit

is irreversible

or unrelated

specifically

as

P.

I

vided I take

Dr. Horton’s article was quite much theoretical material worth exception to his implication that

sine qua syndrome.

non

of all personality

In effect,

the

the article

I . Horton order. 2.

Wis.

in a particular

in

personality

and

level

any sweeping hypotharticle: “An inability [with its locus in the

is the psychopathological condition

.

.

both of clini-

disorders,

the present

cornerstone,

of personality

the

disorder.”

PC: The psychological treatment Am J Psychiatry 133:262-265, 1976

Peele

R,

Rubin

managing

out 4.

DW,

patients

1974 M:

ofMental

of personality

personality:

patients

The

in a training Psychiatric

Manual

hysterical

problem

Houston

American

brain

The

J 67:679-682,

Med Allen

3.

SI:

one ofthe

management

clinic.

and

practice.

South

of hysteroid

Psychiatry

Association:

Disorders,

dis-

identifying

in medical

acting-

22:41-49,

Diagnostic

1959

and

2nd ed. Washington,

connections between paof ‘transitional relatthe absence of transitional relatedness of personality disorder. In support of the

presence

vations

furnish

posits

causal

and

the absence

presumptive

born with conditions. However.

necessary

Statistical

DC, APA,

nondominant that would relatedness.

pp

evidence

for the

inference

that

a

condition

for

personality

disorder

is simply

not

Horton SIR:

their

My

sponse

evidence supporting a link between transitional and personality disorders has been in general isoanecdotal (I). Much of the literature on specific

personality

disorders

actually

tends

to contravene

Dr.

Hor-

ton’s theory. For example. hysterical personalities are noted for their ‘pseudo-insight” (2). This would seem inconsistent with an organically determined anosognosia, which implies a perseverating denial of problems, while ‘pseudo-insight” suggests a shallowness or inconsistency in recognizing them. A more serious difficulty is presented by the obsessive ‘

‘

who,

if anything.

experiences

of transitional relatedness (3). More generally, one may question ing a tenuous ic problem

diagnostic linkage and a disorder that

a pathological

the propriety

between a specific is primarily defined

interpersonal coping strategies. I have come across in either the diagnostic literature or clinical records gest a marked prevalence of chronic disorientation Am

J Psychiatry

/33:12,

December

1976

excess

thanks

to Dr.

Rohmann-Moore

Unfortunately,

to all of the

My article

issues

showed

and

space they

does

have

Mr.

Erard

not permit

for

a re-

raised.

isomorphism

between

salient

features

of personality disorder and minor parietal lobe dysfunction. Misunderstandings arise if one equates ‘ ‘ isomorphic’ ‘ with “reducible to” and subscribes to the traditional medical perspective that asserts the ubiquitous primacy ofcerebral proc-

( I ). We have

esses

disorder (2)-not

described

the sine qua non of personality

as the virtual inability simply and reductionistically

lobe.

There

for

transitional as a disorder

is, in my opinion,

much

relatedness of the pa-

to support

the pos-

tulation of a specific cerebral cause for well-defined ality disorder. However, the genesis of transitional ness, particularly during the first few years of life,

more (3),

study for

before

example,

development

conclusions has

described

of transitional

Evidence for ability to relate

can

be reached.

how

a mother

personrelatedrequires

Coppolillo may

impede

relatedness.

a link between transitionally

personality disorder and inis good (2) but not widely ap-

preciated for two reasons. First, the concept of transitional phenomena has yet to find its way into most psychiatric textbooks. The latest edition of the Comprehensive Textbook of Psychiatry (4) does not even mention the concept. Second,

of accept-

my

neurologthrough

plore

the relationship

sitional

relatedness.

few data that sug(or asso-

D.C.

Replies

comments.

nietal

Clinical relatedness lated and

ERARD

Washington,

Dr.

a panietal lobe dysfunction is, under certain likely to develop some personality disthe conclusion that the brain disorder is a

E.

ROBERT

‘

warranted.

1470

factor

system

REFERENCES

Regarding the latter relationship. he speculates that if a person lacked transitional relatedness, he might be expected to exhibit symptoms similar to those of personality disorders. Finally, he notes that patients with panietal lobe dysfunction are known to have some of the symptoms of personality disorders. notably lack of insight. Taken together, these obser-

patient

.

as

one of the non-psythan here.” relatedness (and its worth investigating

militate against accepting proposed in Dr. Horton’s for transitional relatedness

hemisphere]

necessary

informative and proexploring. However, he has discovered the

former connection, Dr. Horton notes that the parietal lobe is known to handle some functions seem to be important in developing transitional

person other order.

cal evidence esis like that or incapacity

disorders,

41-42

rietal lobe dysfunction edness’ ‘ and between

and

disorders

etiologic

diagnostic

patients sense psycho-

Madison, SIR:

a potential

right

M.D.

ROHMANN-MOORE,

personality

‘

primarily

our present

therapy. DAVID

among

a panietal lobe dysfunction. More to on personality disorders, DSM-II (4) that when ‘the pathological pattern is by the malfunctioning of the brain,

such cases should be classified under chotic organic brain syndromes rather While the phenomenon of transitional possible organic homologies) is certainly

others about making an implausible conorganic brain dysfunction and personality and most important, I hope to keep others

from lending credence to the dismal correlary that with personality disorder are truly ill in a neurologic and thus not amenable to anything but supportive

problems)

prescribes

determined

to

down and thus. deprived of support. the author’s conclusion that there exists a relationship between personality disorder and panietal dysfunction should be viewed with skepticism. My purpose in making this argument is twofold. First,

perceptual

one would expect with the point, in the section

that, although it is difficult, to an awareness of their illthis second analogy breaks

intrapsychic conflict. I believe such patients may be brought ness. Consequently, I think

wish to caution nection between disorder. Second,

ciated

associates

searchers

for diagnosis to ‘deeply ‘

and

should

I are

carefully

of personality ingrained

the

first,

to my

knowledge,

to ex-

between personality disorder and tranWe invite replication. Interested reobserve

disorder,

maladaptive

the

strictures

especially patterns

of DSM-I1

with

of behavior

respect that