Extremes of egocentricity, lack of understanding of the feelings, needs, and actions of others, and an inability to judge one’s own strengths and weaknesses stand as the central issues in a certain type of personality disorder. Such difficulties usually become manifest by adolescence. The complete detachment of the child with psychosis, the amorality of the constitutional sociopath, the major disturbances in thinking of the schizophrenic, and the mood swings of the bipolar also express themselves in many, if not most, instances by adolescence and sometimes by late childhood. Here one confronts a key problem in psychiatry—the extent to which sociopathy has its roots in genetically determined personality traits or in derangements in the affective and social life of the individual consequent to a harmful environment. The answers to these questions cannot be given with finality but most clinicians believe that genetic factors are more important than environmental ones. The discovery that unusually tall males with severe acne vulgaris and aggressive sociopathic behavior may have a karyotype of XYY chromosomes is an extreme but instructive example of a genetic relationship. The patients with Turner syndrome in whom competent social adaptation is linked closely to an X chromosome of paternal origin is another example. Furthermore, there is no critical evidence to show that deliberate alteration of the familial and social environmental measures now so popular have ever prevented sociopathy.
It is during the period of late childhood and adolescence, when the personality is evolving and least stable, that transient symptoms resembling the psychopathologic states of adult life are most frequent and difficult to interpret. Some of these disorders represent the early signs of schizophrenia or bipolar disease. Others are forerunners of sociopathy. But many of these traits have a way of disappearing as adult years are reached so that one can only surmise that they represented either a maturational delay in the attainment of mature social behavior or were expressions of adolescent turmoil, or what has been called “adolescent adjustment reaction.”
Many issues that have been touched upon in the preceding discussion are considered more fully in the section on psychiatric disorders (particularly Chap. 50).
INTELLECTUAL AND DEVELOPMENTAL DISABILITY (SEE ALSO CHAP. 37)
A symptom complex of incomplete development of global cognitive capacities and certain associated behavioral changes combines many of the developmental abnormalities already discussed. What had been called mental retardation and now, intellectual and developmental delay, stands as the single largest neuropsychiatric disorder in every industrialized society. In deference to changed attitudes toward the formerly used term “mental retardation,” we employ alternatives in this text. The overall frequency of the problem cannot be stated precisely but rough estimates are that in children between 9 and 14 years of age, approximately 2 percent or slightly more will be unable to profit from conventional education or to adapt socially and, when grown, to live independently.
Using any one of a number of indices of social and cognitive delay, two somewhat overlapping groups are recognized: (1) the mildly impaired (IQ 45 to 70), and (2) the severely impaired, corresponding to an IQ below 45. The second group, called the pathologically delayed, makes up approximately 10 percent of the impaired population. The more mildly affected first group, which includes a group of the familial developmentally delayed, is much larger.